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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 10/28/2024
Date Signed: 10/29/2024 09:16:22 AM

Document Has Been Signed on 10/29/2024 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WELDWOODSFACILITY NUMBER:
392700402
ADMINISTRATOR/
DIRECTOR:
ETIM, BOKIMEFACILITY TYPE:
735
ADDRESS:1490 PELUSA LNTELEPHONE:
(510) 470-2881
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Bokime EtimTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 10/28/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by facility staff person Erica Lopez who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Bokime Etim, to inform him that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility while this LPA was conducting this visit.
Brief interview conducted with the facility designated Administrator at this time.
Current census was (4) residents, of which, (1) resident was out of the facility at their respective day program at this time.
The purpose of this case management visit was to return the resident file for R1 back to this facility, and its representative, after it was initially taken from this facility on 09/12/2024. This resident file for R1 was accepted back to this facility by the facility designated Administrator Bokime Etim.
Another purpose for this case management visit was to discuss the recent development at this facility with construction of another possible living unit that was taking place in the backyard area of this facility. It was learned that a permit was pulled on 07/22/2024 through the City of Manteca for an Accessory Dwelling Unit (ADU) to be placed behind this facility.
Brief interview was conducted with the facility designated Administrator Bokime Etim in regards to this new construction project taking place.
No prior notice was given to this LPA and any CCL regional office in regards to the new construction.
This facility designated Administrator was informed by this LPA that after discussion with the management team in regards to this new construction project, this LPA will be back out to further discuss any issues, and deficiencies, if any at a later time and date.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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