392700402-11-5-2024-27-AS-CYAG-DAQMVC-20241105085632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 10/30/2024
Date Signed: 11/05/2024 08:56:39 AM

Document Has Been Signed on 11/05/2024 08:56 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:	WELDWOODS		FACILITY NUMBER:	392700402
ADMINISTRATOR/ DIRECTOR:	ETIM, BOKIME		FACILITY TYPE:	735
ADDRESS:	1490 PELUSA LN		TELEPHONE:	(510) 470-2881
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY: 6		CENSUS: 4	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Bokime Etim		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual Licensing visit made out to this facility on 10/30/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Bokime Etim, at this time. A brief interview was conducted with the facility designated Administrator at this time. It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time. This facility is licensed to serve up to (4) Ambulatory only residents and (2) non ambulatory residents for a total of (6) residents at any given time. Current census was 4 residents, of which all (4) of them, were out of the facility at their respectable day programs at this time. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the kitchen cabinet, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WELDWOODS	FACILITY NUMBER: 392700402
	VISIT DATE: 10/30/2024

NARRATIVE

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and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located in the facility hall area leading to the master bedroom, was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguisher was present and observed to be placed near the facility entrance and was recently reviewed on 05/30/2024 by the local fire extinguisher company, Nor Cal Fire Extinguisher, and observed to be in compliance at this time. Garage area was toured.
Administrator certificate for Bokime Etim was observed to be present with certificate #7036136735 set to expire on 07/21/2025.

A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (4) facility resident files was conducted and noted on the following LIC 858.
A review of (4) facility staff files was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were reviewed and a copy was printed and given to the facility designated Administrator at this time. Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/05/2024 08:56 AM - It Cannot Be Edited

Created By: Charlie Yang On 10/30/2024 at 12:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WELDWOODS	FACILITY NUMBER: 392700402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the side wooden perimeter fence, facing the kitchen window, was being held up with a rope tied to another end of the perimeter fence since it needed support to prevent it from falling out onto the sidewalk which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the side wooden perimeter fence will be reviewed by a licensed contractor to repair/replace it to prevent any leaning and potential falling over onto the sidewalk. A statement of correction, along with a copy of the receipt for contracted services, will be completed and submitted into CCL for review by this LPA by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Liza King

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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