<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 05/21/2024
Date Signed: 06/10/2024 10:41:28 AM

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
05/20/2024 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240520141127
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:
05/21/2024
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Orlando CarpioTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to seek medical care for resident with obvious signs of illness
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a 10-Day Complaint Investigation and deliver complaint findings. LPA Valerio met with Administrator Orlando Carpio, and explained the purpose of the visit.

LPA Valerio interviewed Resident 1 (R1), Staff 1 (S1), and Staff 2 (S2). On 05/20/2024, R1 reported having a cough, stuffy nose, sore throat, mucus, and an ear ache. R1 wanted to go to the doctor but staff told her she could no go. According to an interview with R1 on 05/21/24, R1 reported feeling grumpy and did not want any staff making medical appointments for R1. R1 stated R1 called the doctor's office and canceled the appointment made by Administrator Orlando.

According to an interview with S1, S1 stated the facility was trying to refill a medication with the pharmacy on 05/20/2024. The pharmacy stated R1 needed to come in for an appointment prior to receiving additional medication refills.
Continues on LIC 9099 - C... This report was amended to change the report from confidential to public.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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-20240520141127
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: 05/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 9099

S1 stated R1 overheard S1 talking to the doctor's office about R1's appointment. R1 started to yell no and say that R1 wanted to be seen right now. S1 informed R1 that an appointment was made and requested R1 not to cancel. S1 stated R1's family member contacted S1 to inform that R1 is attention seeking.

According to an interview with S2, S2 was with R1 when R1 requested to go to the doctor due to having a stuff nose. S2 gave R1 nasal spray to address the symptom. R1 became agitated, yelled, left the table, and went to R1's room. S2 stated that staff will no leave R1. We will not abandon R1. If R1 needs medical attention, of course, staff will call 911 or use our facility vehicle. We will always be there fro R1."

According to Medication Administration Records (MAR), staff provided medications to R1 for symptoms.

The department has determined the following as it relates to the allegations that Staff refused to seek medical care for resident with obvious signs of illness:

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 allegation. An exit interview was held and a copy of this report was left.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2