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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 11/22/2024
Date Signed: 11/26/2024 08:48:17 AM

Document Has Been Signed on 11/26/2024 08:48 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:
11/22/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Bokime EtimTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Announced Office Informal Meeting was conducted at 702 N Aurora St Stockton CA on 11/22/2024 by Licensing Program Manager (LPA) Liza King and Licensing Program Analyst (LPA) Charlie Yang who were also joined by the following individuals:
  1. Community Services Director Brian Bennett
  2. Valley Mountain Regional Center (VMRC) Division Manager of Quality Assurance Katina Richison
  3. Community Services Liaison Deanna Fantulin
  4. SCSL Anna Sims
  5. Community Services Liaison Alondra Villagomez
  6. Community Services Liaison Shannon Hernandez
  7. Facility Licensee Bokime Etim-Participated via conference call
The purpose of this meeting was to conduct an Informal Meeting and follow up with the facility Licensee Bokime Etim in regard to some recent events and incidents that have taken place at this facility.
The following issues were discussed and reviewed at this time:

· Facility Program-Changes and Updates
· Reporting Requirements
· Personal Rights

The facility Licensee Bokime Etim will complete and submit the following:
  • An updated facility program addressing policies and procedures with resident care and supervision. The focus of this update will be in relation to resident changes in levels of care and supervision and how this
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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: 11/22/2024
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facility will intend to handle and take proper care of the residents in order to maintain the proper acceptance and retention levels. These changes will also be reflected in how facility staff will deal with these changes to the residents and how to properly report and submit any such incidents into CCL within the required time frames.

· LIC 500
· LIC 308

This facility Licensee was given until the COB of 11/30/2024 to complete and submit the above forms and documents into CCL for review.

In addition, the Licensee agreed that the following will be put into place:
  1. The Administrator will be present at least 40 hours a week during the increased monitoring time period. These hours will be reflected on the updated LIC 500 provided to CCL.
  3. Facility residents will be able to participate and hold resident council meetings on a regular basis. Proof of notes and minutes will be taken and provided to CCL.
  5. Proof of facility resident outings, on a weekly basis, will be provided to CCL for review on a monthly basis.
A discussion was held about the facility Licensee’s voluntary engagement with Technical Support Program (TSP). Licensee did not agree to participate in TSP.

CCL will increase monitoring over the next 12 months to provide oversight and guidance as needed.

No citations were issued during todays meeting and a copy of this report will be provided to this Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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