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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700914
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:06:46 PM

Substantiated


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
07/23/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240723091923
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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Orlando CarpioTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff transported a resident in an unsafe manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Orlando Carpio and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Carpio, three staff members (S1-S3), and one resident (R1).

Based on interviews with Carpio, facility staff (S1), day program staff (S2), and based on daily notes for R1, R1 was taken to day program on the morning of 7/16/24. However, R1 continued to be disruptive in program, which led to R1 being picked up early from program by S3.

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

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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 5
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
07/23/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240723091923

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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Orlando CarpioTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff confiscated resident's phone.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Orlando Carpio and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Carpio, three staff members (S1-S3), and one resident (R1).

Based on interviews with Carpio, facility staff (S1), day program staff (S2), and based on daily notes for R1, R1 was taken to day program on the morning of 7/16/24. However, R1 continued to be disruptive in program, which led to R1 being picked up early from program by S3.

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

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240723091923
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: 08/06/2024
NARRATIVE
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In an interview, S2 said that R1 was on their phone and was not engaged with the group, and after being told that R1 needed to get off their phone and engage with the program, R1 became agitated and called 911. S2 said that day program staff and facility staff agreed it would be best to have R1 brought back to their facility. In an interview, S1 said that R1 was making false allegations about their day program teacher stealing their phone while at day program.

In an interview, R1 alleged that S3 took their phone while driving back from the day program. In an interview, S3 denied having done so. There were no additional witnesses to corroborate either narrative.

R1's most recent IPP states that R1 has a history of making false allegations about peers and staff.

The department has determined the following as it relates to the allegation that staff confiscated a resident's phone:

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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240723091923
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: 08/06/2024
NARRATIVE
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In an interview, R1 said that S3 was driving unsafely by driving with one hand and using the other hand to take video on S3's phone. In an interview, S3 admitted to taking video with their phone while driving. S3 said that they were using the video to document the fact that S3 was driving at a safe speed by pointing the camera at the speedometer. There were no other staff members or residents in the vehicle at the time. The video was deleted, according to S3. Driving while actively using a mobile device is illegal in California, as it distracts drivers from the road, and is therefore unsafe.

The department has determined the following as it relates to the allegation that staff transported a resident in an unsafe manner:

Based on interviews, this allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 80072(a)(2). An exit interview was held with Carpio. Appeal rights and a copy of this report was left with Carpio.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240723091923
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
80072(a)(2)
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Personal rights: "(2) To be accorded safe, [and] healthful ... accommodations..."
This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding safe driving practices.
vincent.moleski@dss.ca.gov
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Based on interviews, S3 was using a mobile device while driving, which poses an immediate health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5