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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:06:40 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231113084848
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:
11/16/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Orlando CarpioTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident was forced to take medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to investigate this complaint. LPA Moleski met with facility administrator Orlando Carpio and explained the purpose of the visit.

This investigation consisted of interviews and record review.

LPA Moleski interviewed a resident (R1). R1 said that S5 had forced pills into R1’s mouth on more than one occasion. LPA Moleski interviewed five staff members (S1-S5) and Carpio. All five staff members and Carpio denied that any staff had forced R1 to take medications. Carpio said the facility’s protocol is to give reminders if a resident does not want to take their medications. LPA Moleski interviewed a resident (R2). R2 said staff do not force R2 to take any medications.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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-20231113084848
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: POND BROOK HOME, INC.
FACILITY NUMBER: 342700914
VISIT DATE: 11/16/2023
NARRATIVE
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LPA Moleski reviewed an incident report dated Nov. 10 which described an incident that occurred on Nov. 9. On Nov. 9, R1 refused to take medications and alleged that R1 was being forced to take medications, according to the incident report. Law enforcement was called and an officer spoke with R1, according to the incident report. No further action was taken by law enforcement, according to the incident report. LPA Moleski reviewed R1’s IPP. R1’s IPP notes that R1 has a history of refusing medications and making false allegations about staff members and others. LPA Moleski reviewed R1’s medication administration records (MARs). R1’s MARs for the month of November showed that R1 had refused medications on Nov. 9 through Nov. 11, Nov. 13, and Nov. 16.

The department has determined the following as it relates to the allegation that a resident was forced to take medications:

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

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Carpio.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2