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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700914
Report Date: 01/11/2023
Date Signed: 01/11/2023 01:04:05 PM

Document Has Been Signed on 01/11/2023 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Orlando Carpio - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of today’s visit.
Administrator Certification #6024159735 expires on 10/26/2023. There are currently four (4) clients who reside at this facility.

LPA and administrator inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature registered 107.3 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 73 degrees Fahrenheit. Food supply is adequate for 2 day perishable and 7 day nonperishable. Smoke and carbon detectors were in good repair. Fire extinguishers were last serviced on 12/8/2022 and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed two (2) resident files and two (2) staff files. LPA reviewed resident and staff roster. LPA reviewed staff associations to the facility.
The facility mitigation plan was submitted to CCLD on 7/29/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had COVID-19 posters throughout the facility.

LPA requested the following forms to be submitted via email by February 6, 2023:
LIC 308 - Designation of Administrative Responsibility, LIC 610-D - Emergency Disaster Plan, Current Surety Bond, and Administrator Certificate.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted with administrator and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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