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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320138
Report Date: 11/04/2025
Date Signed: 11/04/2025 08:57:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251028121247
FACILITY NAME:BRIDGES TO RECOVERY, LLCFACILITY NUMBER:
198320138
ADMINISTRATOR:MICHAELA CARPACCIOFACILITY TYPE:
772
ADDRESS:725 FOOTHILL ROADTELEPHONE:
(310) 275-4620
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90210
CAPACITY:6CENSUS: 6DATE:
11/04/2025
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Malia Lindy/Program DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not update needs and services plan as needed.
INVESTIGATION FINDINGS:
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On 11/4/2025 at approximately 10:00 AM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with /Program Director. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Program Director Interview (A#1), Clients Interviews (C#1-C#6), and Facility Staff Interviews (S#1-S#4). LPA gathered the following documents: Client Roster dated: 11/4/25, Staff Roster dated:11/4/25, copy of (C#1-C#3) Physicians Report for Community Care Facilities or LIC 602, copy of (C#1-C#3) Admission Agreement, Copy of (C#1-C#3) Identification and Emergency Information or LIC 601, copy of (C#1-C#3) Appraisal/Needs and Services Plan or LIC 625, copy of (C#1-C#3) prescribed medications and copies of staff summary notes with various dates.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
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 4
Control Number 11-AS-20251028121247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRIDGES TO RECOVERY, LLC
FACILITY NUMBER: 198320138
VISIT DATE: 11/04/2025
NARRATIVE
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 Investigation Revealed the Following:

Allegation: Staff did not update needs and services plan as needed.

The complaint alleges that facility staff failed to update (C#1)’s Appraisal/Needs and Services Plan following a reported mental health episode.

On November 4, 2025, at approximately 2:00 PM, during the records review, LPA Iniguez examined (C#1)'s copy of the Appraisal/Needs and Services Plan (LIC 624) dated August 14, 2025. LPA Iniguez noted that this is the only plan on file for (C#1) and that there is no updated version following the changes in (C#1)'s mental condition.

On 11/4/2025, at approximately 10:30 am during an interview with the program director (A#1), she stated that (C#1) needs and services plan has not been updated since they were admitted on 8/12/25 and the person that updates the plan is the therapist.

On November 4, 2025, at approximately 11:30 am, during an interview with Client #1 (C#1), they reported that the facility staff did not discuss their needs and services plan with them and that it had not been updated following their recent events. (C#1) also mentioned that their current plan does not adequately reflect their mental health or emotional well-being needs.

On 11/4/2025, at approximately 11:00 am, during an interview with facility staff (S#1-S#4), (4) out of (4) stated that they were unaware of when (C#1)’s Appraisal/Needs and Services Plan was last updated. However, (4) out of (4) facility staff stated that (C#1)’s current Appraisal/Needs and Services Plan reflects their mental and physical needs.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20251028121247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRIDGES TO RECOVERY, LLC
FACILITY NUMBER: 198320138
VISIT DATE: 11/04/2025
NARRATIVE
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During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted, and a copy of the Complaint Report was given to Malia Lindy/Program Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20251028121247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRIDGES TO RECOVERY, LLC
FACILITY NUMBER: 198320138
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2025
Section Cited
CCR
81068.2(c)(2)
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81068.2 NEEDS AND SERVICES PLAN
(c) If the client has an existing needs appraisal...
(2) The licensee and the placement agency agree that the client's physical, mental and emotional...
This requirement was not met as evidence by:
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Licensee will adhere to Title 22 at all times. As plan of correction the licensee will re-train the clinical staff if there are notable changes on clients behavoirs. Proof of correction will be sent to LPA Iniguez via email.
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Based on record review and interviews, the licensee failed to update (C#1)'s Needs and Services Plan to reflect significant changes in their mental and emotional condition. This poses a potential health and safety risk to residents in care.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4