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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:04:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221012131341
FACILITY NAME:POND BROOK HOME, INC.FACILITY NUMBER:
342700914
ADMINISTRATOR:CARPIO, ORLANDOFACILITY TYPE:
735
ADDRESS:8183 POND BROOK WAYTELEPHONE:
(916) 476-0882
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:OrlandonCarpuioTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Staff forced a client to take their medication while in care
INVESTIGATION FINDINGS:
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On 10/21/22 at 9:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a a complaint investigation in to the above listed allegation. LPA Jensen met with Delson Bautista, house manager, and was later joined by Orlando Carpio, Licensee. LPA Jensen explained the purpose of today's visit to both parties.

During the course of the visit LPA Jensen reviewed the following records:
Medication Administration Records (MARs) for resident 1(R1) and resident 2 (R2)
Medication destruction records for R1
IPP for R1
Staff roster and contact information

Continued on LIC 9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20221012131341
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: POND BROOK HOME, INC.
FACILITY NUMBER: 342700914
VISIT DATE: 10/21/2022
NARRATIVE
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There were 3 residents present at the time of the visit, . LPA Jensen interviewed 3 of 3 residents. There were 3 staff present, LPA Jensen interviewed 3 of 3 staff in person. LPA Jensen also interviewed 2 staff members by telephone.

5 of 5 staff members gave consistent accounts of how medication refusals are handled. All staff members interviewed denied ever having forced or coerced a resident in to taking medications. All staff denied ever having seen or heard of another staff member forcing or coercing a resident to take medications. The procedure described by staff for residents refusing medication is to wait and try administering the medication at a later time but within the hour. If the resident continues to refuse the medication to circle initials on the MAR and notify house manager or licensee. The medication then gets destroyed.

The medication destruction record reviewed was consistent with the timing of the complaint. Medication refusals were observed to be documented in the MARS and were consistent with staff accounts.

Interviews with residents produced no evidence to support that medication was forced on a resident at any time.

Based on interviews conducted and records reviewed this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not support the incident occurred.

No deficiencies are being cited during the course of this visit.

An exit interview was conducted and a copy of this report along with appeal rights was given to the Licensee.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2