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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700914
Report Date: 06/27/2024
Date Signed: 07/02/2024 04:45:44 PM

Document Has Been Signed on 07/02/2024 04:45 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:POND BROOK HOME, INC.FACILITY NUMBER:
342700914
ADMINISTRATOR/
DIRECTOR:		CARPIO, ORLANDOFACILITY TYPE:
735
ADDRESS:8183 POND BROOK WAYTELEPHONE:
(916) 476-0882
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
06/27/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Orlando CarpioTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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An informal meeting was held today, June 27, 2024, in order to discuss complaints that have been filed against this facility by a particular client (R1), all of which have been resolved as either unsubstantiated or unfounded. Licensing Program Analyst (LPA) Vincent Moleski, Licensing Program Manager Stephen Richardson, Alta California Regional Center (ACRC) Facility Liaison (FL) Kara Zwick, ACRC Service Coordinator (SC) Sharon Mendy, ACRC Client Services Manager (CSM) Heather Hollingworth, and facility licensee/administrator Orlando Carpio were in attendance.

LPM Richardson discussed the allegations made in previous complaints and asked what the facility had done to address concerns. Regarding medications, Carpio said that staff were no longer asking R1 repeatedly if they want to take their medication, and are documenting all refusals in shared information sent to ACRC.

Regarding resident supervision, Carpio said that R1 is receiving one-on-one supervision, and ACRC staff in attendance noted no concerns with staffing at the moment. Carpio said R1 does sometimes want privacy in their room, which staff respect.

SC Mendy said she has established scheduled calls with R1 to discuss any concerns that R1 may have on a regular basis. SC Mendy said R1 wanted to return to a day program and progress was being made on enrolling R1 back into their program.

Regarding medical treatment, Carpio said that staff continue to send R1 to urgent care or call for paramedics when requested. LPM Richardson recommended that Carpio provide refresher trainings for staff on mandated reporting to ensure that any legitimate concerns were reported immediately upon observation by staff.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2024
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According to Carpio, R1 is no longer taking any mental health medications due to influence from a family member. LPM Richardson said that R1's refusal to take mental health medications may potentially cause behaviors sufficient to justify the issuance of a 30-day notice. SC Mendy was aware of this issue and has attempted to discuss matters further with R1's family member. CSM Hollingworth said that involving an ACRC client advocate may be beneficial.

LPM Richardson instructed Carpio to continue maintaining staffing as determined by ACRC personnel and to continue documenting issues surrounding R1 as much as possible. LPM Richardson offered Technical Support Program services to Carpio, who agreed to a referral.

No deficiencies were cited during this visit. An exit interview was held with Carpio and a copy of this report was sent for him to sign.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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