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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:19:21 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
05/28/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240528163210
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:
05/29/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Orlando CarpioTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff member assaulted resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Orlando Carpio and explained the purpose of the visit.

This investigation consisted of interviews, observations, and record review. LPA Moleski interviewed Carpio, two residents (R1-R2), and four staff members (S1-S4).

During an interview, a resident (R1) alleged that a staff member (S4) pushed R1 to the floor and put R1 in a restraint on Monday, May 27, 2024 around 4 p.m. R1 said that Carpio and S3 witnessed the incident. R1 said there were no other witnesses.

LPA Moleski interviewed Carpio and four staff members (S1-S4). In an interview, S4 denied the allegation as described above and said there were no disagreements between S4 and R1. In an interview, Carpio said he was present at the facility Monday afternoon and did not observe any staff members pushing or restraining any resident. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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-20240528163210
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: 05/29/2024
NARRATIVE
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S1-S3 worked with S4 on Monday, May 27, 2024. In interviews, S1-S3 said they had not witnessed S4 pushing or restraining R1 on that date or on any other date.

During an interview, R2 said that S4 was "cool," and that R2 had never witnessed S4 acting violently.

LPA Moleski did not observe any unusual or suspicious injuries present on R1.

LPA Moleski reviewed daily notes for R1 dated May 27, 2024. The notes describe R1 visiting the hospital in the morning, and getting upset in the afternoon because staff mopped the dining room floor. R1 called 911, and responding officers left without incident, according to the notes.

LPA Moleski reviewed R1's most recent IPP. The IPP indicates that R1 has a history of lying and making false allegations about staff and peers.

The department has determined the following as it relates to the allegation that a staff member assaulted a resident:

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 violation occurred.

No deficiencies were cited regarding the above allegation. 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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2