342700914-9-25-2023-27-AS-KHOS-CW3SF8-20230927134954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 09/25/2023
Date Signed: 09/25/2023 02:06:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
07/07/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230707092206

FACILITY NAME:	POND BROOK HOME, INC.		FACILITY NUMBER:	342700914
ADMINISTRATOR:	CARPIO, ORLANDO		FACILITY TYPE:	735
ADDRESS:	8183 POND BROOK WAY		TELEPHONE:	(916) 476-0882
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	4	CENSUS: 4	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Orlando Carpio		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident was assaulted by another resident.
Staff are not adequately supervising residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Orlando Carpio and explained the purpose of the visit.

This investigation consisted of observations, resident interviews, staff interviews, an interview with a facility behaviorist (B1), an interview with a behavior intervention consultant (B2), an interview with an Alta California Regional Center (ACRC) service coordinator, and record review.

LPA Moleski reviewed an incident report that described an incident that occurred on July 5, 2023. According to the report, R2 ran toward R1 and hit R1 in the arm. The report states that staff immediately got in between the residents to deescalate the situation. Staff redirected both residents “to prevent further harm,” according to the report. Three staff members, S6, S7, and S8 were present during the incident, according to the report. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230707092206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: POND BROOK HOME, INC.	FACILITY NUMBER: 342700914
	VISIT DATE: 09/25/2023

NARRATIVE

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LPA Moleski interviewed R1, R2, and R3. In an interview, R1 said that staff tried to break up the argument, and that they got in between R1 and R2 to protect R1. R2 and R3 described adequate staffing levels at the facility. R3 said staff told R3 to stay in their room during the altercation.

LPA Moleski interviewed seven staff members (S1-S7). S6-S8 all described attempts to deescalate the altercation described in the incident report. S6-S8 said S6 attempted to redirect R2 to take a car ride. S6-S8 said R2 went outside, but then ran back inside to attack R1. S6-S8 said S7 and S8 remained inside with R1 and got in between R1 and R2 during the attack. During an interview, Carpio said that, when R2 becomes aggressive, staff are instructed to tell other residents to stay in their rooms, to get in between R2 and any other resident involved, and to try to remove R2 from the situation in order to protect other residents.

During interviews with S1-S7, S3, S4, and S8 voiced concerns regarding staffing levels at the facility.

LPA Moleski interviewed an ACRC service coordinator. The service coordinator said facility staff do “the best they can” supervising and redirecting R2. The service coordinator did not voice concerns regarding supervision at the facility.

In an interview, B1 described aggression reduction techniques recommended to facility staff, including verbal redirection and separating residents from R2 when agitated. B1 did not voice concerns regarding the facility’s ability to provide supervision over R2 or to implement these techniques. In an interview, B2 described behavior prevention techniques, including providing reinforcement for good behavior and removing demands when aggression emerges. B2 did not voice concerns regarding this facility’s ability to provide supervision over R2, but recommended two-to-one supervision for R2. LPA Moleski reviewed a statement written by Carpio received by CCLD on 9/13/23 which states, in part, that facility staff have been instructed to provide two-to-one supervision for R2.

During the course of this investigation, LPA Moleski visited this facility four times, not including this visit. On each of these occasions, LPA Moleski observed adequate levels of staffing and supervision.

[continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230707092206

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: POND BROOK HOME, INC.	FACILITY NUMBER: 342700914
	VISIT DATE: 09/25/2023

NARRATIVE

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LPA Moleski reviewed staffing schedules dated from May 2023 through July 2023 and observed adequate staffing levels.

LPA Moleski reviewed R2’s individual program plan (IPP). The IPP states that R2 receives one-on-one supervision. LPA Moleski reviewed staffing schedules for the week of July 2 through July 8, 2023 and observed adequate staff scheduled to provide supervision during this time frame. LPA Moleski reviewed a behavior intervention plan for R2. The plan identifies several techniques to be implemented when R2 becomes agitated, including redirection, lifting demands, and providing attention. In interviews, staff members described using these sorts of techniques to deescalate situations involving R2.

The department has determined the following as it relates to the allegations that a resident was assaulted by another resident and that staff are not adequately supervising residents:

Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Although a resident was assaulted by another resident on July 5, 2023, this allegation is unsubstantiated as facility responsibility for the incident has not been proven to the preponderance of evidence standard.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Carpio.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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