<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700914
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:10:15 PM

Document Has Been Signed on 08/31/2023 03:10 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
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:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Orlando CarpioTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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.

The incident report described an incident that took place on 7/31/23, wherein 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 was parking the car. The staff member saw R1 running out of the store. R1 returned to the facility 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.

Carpio said S1 was present at the time, and has since quit working at the facility. LPA Moleski called S1 but did not receive an answer. 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."

No deficiencies were cited during this visit. 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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1