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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 11/21/2024
Date Signed: 11/26/2024 08:47:44 AM

Document Has Been Signed on 11/26/2024 08:47 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:
11/21/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Bokime EtimTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Unannounced Plan of Correction visit made out to this facility on 11/21/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Bokime Etim. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 4 residents..
The purpose of this visit was to follow up on the deficiency that was cited from a prior annual visit conducted on 10/30/2024. This visit was to follow up on the Plan of Correction that was due.

The following deficiency was observed and cited on 10/30/2024:
  • 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.


Plan of Correction clearance letters were printed and copies provided to the facility designated Administrator at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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