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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700914
Report Date: 09/08/2023
Date Signed: 09/08/2023 10:13:12 AM

Document Has Been Signed on 09/08/2023 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Orlando CarpioTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski met with administrator Orlando Carpio and explained the purpose of the visit.

LPA Moleski reviewed an incident report which described an incident that took place on 7/31/23. According to this incident report, a resident (R1) took a walk outside and was followed by staff in a vehicle. R1 went inside a nearby store, while the staff member (S1) was parking the car. S1 then saw R1 running out of the store. S1 spoke with R1 "to figure out what happened," according to the report. R1 returned to the facility with S1 in the vehicle. Police later arrived at the facility and notified staff that R1 had allegedly stolen a pencil and threatened an employee of the store.

LPA Moleski interviewed S1 on 8/31/23. S1 said R1 was inside the store for two or three minutes while S1 was parking the car.

LPA Moleski interviewed R1's Alta California Regional Center Service Coordinator on 9/8/23. The service coordinator said staff must maintain a line of sight on R1 while outside of the facility as part of R1's one-on-one supervision. R1's IPP states that R1 receives one-on-one supervision.

LPA Moleski reviewed R1's LIC 602. According to the LIC 602, R1 may leave the facility unassisted "with caregiver supervision."

This facility is being cited per 22 CCR Section 80065(a). An exit interview was held with Carpio. Appeal rights and a copy of this report were left with Carpio.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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Document Has Been Signed on 09/08/2023 10:13 AM - It Cannot Be Edited


Created By: Vincent Moleski On 09/08/2023 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: POND BROOK HOME, INC.
FACILITY NUMBER: 342700914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
80065(a)

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Personnel Requirements: "(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs."

This requirement was not met as evidenced by:
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Licensee agrees to write a plan to address staffing needs for R1. Licensee further agrees to send LPA Moleski of copy of that statement.
vincent.moleski@dss.ca.gov
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Based on review of an incident report, and based on interviews with staff and an Alta California Regional Center service coordinator, R1 was not supervised while out in the community, as required by R1's LIC 602, and staff did not maintain a line of sight on R1, as required by Alta California Regional Center, which poses a potential 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
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