342700914-5-23-2024-27-AS-KHOS-D5XRUJ-20240605132000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:39:07 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
05/07/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240507092832

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:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Rona Agoncillo		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff member physically abused resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a complaint investigation and deliver complaint investigation findings. LPA Valerio met with facility staff, and explained the purpose of the visit.

On 05/07/2024, The Department received a report that a resident was allegedly abused by a staff member. According to the Reporting Party (RP), the RP was unsure if the information was true as the information was told to RP.

On 05/10/2024, LPA Valerio interviewed 3 residents. Resident 1 (R1) stated that Staff 2 (S2) caused a bruise on right hand, a scratch on the right side of the head, and hurt R1's rib cage. R1 provided a picture of R1's hand, which showed an unclear photo of thumb and hand with a slight discoloration to skin. R1 did not have a picture of one's face.
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240507092832

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: 05/23/2024

NARRATIVE

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Continues from LIC 9099

According to an interview with Resident 2 (R2), R2 reported the facility to be a good place to live. R2 denied seeing staff hit a resident. R2 denied ever being abused by staff. R2 stated R2 does not have a favorite staff because all of favorites. According to an interview with Resident 3 (R3), R3 reported that staff have not touched R3 and has not seen staff touch another resident.

On 05/10/2024, LPA Valerio obtained permission from R1 to take picture of R1's hand and face for future reference. LPA Valerio did not observe any scratches on R1's face nor was a bruise observed on R1's hand.
LPA Valerio reviewed Facility Records. The facility staff document details of each resident's day on a hourly log. LPA Valerio reviewed On-going Notes for R1. Notes revealed that R1 contacted 911 to report being abused and R1's hand being hurt. Police and the Fire Department arrived to the facility and left within minutes of arriving due to observing nothing wrong with hand. It should be noted that R1 had documented behaviors prior to the call to 911.

On 05/21/2024, LPA Valerio received a voicemail and LPA Moleski received a phone call from R1 alleging that S2 was on shift and hit R3 in the face. On 05/21/2024, LPA Valerio was on-site for a visit related to another complaint (27-AS-20240520141127). During LPA's visit, LPA documented R3's behaviors and the interactions between staff and residents. LPA Valerio did not observe any staff hit R3.

LPA Valerio interviewed 4 staff members. S1, S2, S3, and S4 deny ever seeing staff hitting a resident and deny ever hitting a resident. According to an interview with S2, S2 is assigned to work with other residents and not with R1. S2 stated the day S2 was accused, S2 never stepped foot in R1's room or interacted with R1. Interviews with other staff confirm these statements.

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. An exit interview was held and a copy of this report was left. Due to Administrator having an appointment at another licensed facility, Administrator Orlando appointed designated staff to sign on his behalf.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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