342700914-5-16-2024-27-AS-KHOS-D5XQXF-20240605123329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:27:26 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
05/10/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240510143805

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:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Orlando Carpio		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent a resident from injuring another resident in care
Staff did not prevent resident from making inappropriate comments to another resident in care

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 Carpio, two residents (R1-R2), and four staff members (S1-S4).

In an interview, R1 said that on May 4, 2024, R1 was playing music when R2 attacked R1. R1 said R2 punched R1 in the back, but later recanted and said that, actually, R2 had only tried to attack R1. R1 said that R2 had cursed at R1 because R1 was playing music. R1 changed their story multiple times during the interview. R1 said that R2 was arrested and went to jail after the incident described, but then later said that, actually, R1 had only been told secondhand by staff about the arrest, then again that R1 had been told secondhand by R2 that R2 had gone to jail. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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-20240510143805

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: 05/16/2024

NARRATIVE

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In an interview, R2 said that there was no physical altercation or fight between R1 and R2. R2 said that R2 had told R1 to “shut the fuck up” because R1 was playing music too loudly. R2 said that R2 was taken by staff for a car ride.

In interviews, four staff members (S1-S4) who were working over the weekend of May 4 through May 5 said there was no physical altercation between R1 and R2.

S1 said that there was a quarrel between R1 and R2 because R1 was playing music loudly. S1 said that the other residents did not appreciate the loud music. S1 said R2 told R1 to “shut the fuck up.” S1 said that S1 took R2 for a car ride to redirect R2. S2 said that R2 was shouting at R1 due to the loud music, and S1 took R2 for a car ride to redirect R2. S3 said R1 and R2 often have arguments due to R1 playing loud music. S3 said that during these times, staff will redirect R2 by playing video games or by taking R2 on a car ride. S4 said that R2 was complaining about R1’s music but it did not escalate from there and R2 was redirected.

LPA Moleski reviewed R1 and R2’s files. R1’s IPP indicates that R1 has a history of lying and making false allegations about staff and peers. A behavior intervention plan for R2 indicates that attention from staff and car rides may be used to reduce behaviors including verbal threats. LPA Moleski reviewed daily notes for R1 and R2. R1’s notes for May 4 do not indicate any unusual incidents. R1’s notes for May 5 indicate that R1 got into an argument with R2. R1 called the police and staff redirected R2, according to the notes. R2’s daily notes indicate that R2 went for a car ride around 5 p.m. on May 4. R2’s notes for May 5 indicate that R2 got into a verbal disagreement with R1 around 6 p.m. but returned to their room to play video games.

The department has determined the following as it relates to the allegations that staff did not prevent a resident from injuring another resident in care and that staff did not prevent a resident from making inappropriate comments to another resident in care:

Based on interviews 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.

No deficiencies were cited regarding the above allegations. 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: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

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