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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:36:04 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
07/19/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240719113551
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: 3DATE:
07/22/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Orlando CarpioTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff kicked resident's car seat.
Staff spoke inappropriately to a resident in care.
Staff are not allowing resident to call Law Enforcement.
Staff did not prevent a resident from threatening another resident in care.
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 clients (R1-R2), and eight staff members (S1-S8).

During an interview, R1 described a verbal disagreement between R1 and R2 which took place on or around 7/18/24. R1 said that R2 had threatened R1. During an interview, R2 said that they had merely told R1 to mind their own business, but admitted to being frustrated with R1 due to repeated false allegations made to law enforcement since 7/18/24, which resulted in police officers visiting R2 several times.

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

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
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 4
Control Number 27-AS-20240719113551
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: 07/22/2024
NARRATIVE
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R2 said that staff had helped R2 to calm down, and told R2 to try to ignore R1. LPA Moleski reviewed daily notes for R1 and R2 dating between 7/18/24 and 7/21/24. The notes indicate that R2 was redirected, and R2 went back to their room. Carpio said that he had also spoken over the phone with R2 in an attempt to calm R2 down. All staff interviewed who had been present during the verbal disagreements between R1 and R2 corroborated the narrative provided in the daily notes, which is that R2 and R1 were both redirected in order to prevent further escalation.

R1 described an incident which allegedly took place on 7/18/24 wherein R1 was being taken to a medical appointment by two staff members (S2-S3). R1 said that S3 had kicked their car seat, told R1 not to call the police, and told R1 to "shut up." LPA Moleski interviewed S2 and S3. S2 denied having witnessed any of the incidents described by R1 during the car ride. S3 denied having done any of the acts alleged by R1. Daily notes for R1 show that R1 was redirected from calling 911 for non-emergency matters. Staff interviews suggested that R1 is encouraged not to call 911 if there is not an active emergency ongoing.

R1's most recent IPP states that R1 has a history of making false allegations about peers and staff. Near the end of LPA Moleski's visit, R1 spoke with LPA Moleski, saying "sorry about the false allegations."

The department has determined the following as it relates to the allegations that staff kicked resident's car seat, staff spoke inappropriately to a resident in care, staff are not allowing resident to call law enforcement,
and that staff did not prevent a resident from threatening another resident in care:

Based on interviews, 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: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4