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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320220
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:30:45 PM

Unsubstantiated


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
08/05/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240805163836
FACILITY NAME:BRIDGES TO RECOVERY-MAPLE DRIVEFACILITY NUMBER:
198320220
ADMINISTRATOR:MICHAELA CARPACCIOFACILITY TYPE:
772
ADDRESS:721 MAPLE DRIVETELEPHONE:
(310) 275-4620
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90210
CAPACITY:6CENSUS: 1DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Michaela Carpaccio /Executive Clinical Director. TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Client was injured due to lack of supervision from staff.
Facilities boundary wall is in disrepair.
INVESTIGATION FINDINGS:
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On 8/9/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Michaela Carpaccio /Executive Clinical Director. LPA explained the purpose of this visit was to investigate complaint.

Investigation Consisted of: LPA conducted the following interviews: Program Director Interview(P#1), Client’s interviews (C#1 and C#2) and Facility Staff (S#1-S#2). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (C#1) Identification and Emergency Information, (C#1) Admissions agreements, (C#1) Physicians Report for Residential Care Facilities for the Elderly, (C#1) Needs and Services Plan, (C#1) Medication Administration Record (MAR) for the month of July 2024, a health and safety check of the facility, copy od SRI dated 7/15/24 regarding (C#1)’s incident and copy of (C#1)’s pet agreement.

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

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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-20240805163836
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-MAPLE DRIVE
FACILITY NUMBER: 198320220
VISIT DATE: 08/09/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Client was injured due to lack of care & supervision from staff.

The details of the complaint alleged that a client in care was injured due to lack of care & supervision from staff.



During the records review, LPA Iniguez examined (C#1)'s Physicians Report for Community Care Facilities (LIC 602). It indicates that C#1 is capable of leaving the facility unassisted, walking without assistance, and does not require constant medical supervision. Additionally, LPA reviewed the Unusual Incident Report (LIC 624), which states that two facility staff members were present when C#1 climbed the neighbor's wall and sustained an injury. C#1 was never alone at the time of the incident. Furthermore, LPA review (C#1)’s care level, (C#1) was on a 30 minute check by facility staff.

During a facility tour, LPA observed two facility staff members, one chef, and one clinician. The facility currently has one client.

During an interview with the Executive Clinical Director (P#1), she stated that the client-to-staff ratio has changed from three staff members for every two clients to two staff members for every one client this is due to the current census. While (C#1) was living here, there were three clients, three facility staff, and clinicians and management available for any emergency. In addition, (P#1) stated that (C#1) got injured because they chased after their dog and climbed the neighbor’s wall, not because of a lack of supervision from facility staff. (C#1) was on a 30-minute supervision level at that time.

During interviews with facility staff (S#1-S#2), (2) out (2) stated that the facility ratio is two staff per client. Also, (2) out of (2) facility staff stated that (C#1) got injured not for lack of supervision from facility staff but because they were chasing after their dog that crossed into the neighbor’s property.

Evaluation Report continues LIC 9099-C

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

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240805163836
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-MAPLE DRIVE
FACILITY NUMBER: 198320220
VISIT DATE: 08/09/2024
NARRATIVE
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During interviews with clients (C#1 and C#2), (2) out of (2) clients stated that there are always facility staff present day and night; they are never alone. Also, (2) out of (2) clients said that they have never been injured due to the facility's lack of care and supervision; only (C#1) stated that they got hurt because they were chasing after their dog. In addition, (2) out of (2) clients stated they feel safe living here.

Allegation: Facility boundary wall is in disrepair.

The details of the complaint alleged that the facility boundary wall is in disrepair.

During the records review, LPA observed a “Wall agreement, released and indemnity” contract filed at the Recorder’s Office on 9/10/1996. The document states that “both parties wish to settle their differences and release and discharge one another and their successors of and from any further liability or responsibility with respect to the wall or trees as defined herein.”

During a tour of the facility, LPA observed that the wall where (C#1) got injured is on the side of the neighbor’s wall; the facility has a tree line as a wall, and after the incident, the facility added a mid-side metal fence to prevent clients’ pets from crossing to the neighbor’s property. LPA proceeded to take pictures as evidence.

During an Interview with the Executive Clinical Director (P#1), she stated that the wall where (C#1) got injured belongs to the neighbors, and there is a legal document that stipulates that 421 N Maple Drive will be free from liability regarding that wall.

Evaluation Report continues LIC 9099-C

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

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240805163836
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-MAPLE DRIVE
FACILITY NUMBER: 198320220
VISIT DATE: 08/09/2024
NARRATIVE
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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Michaela Carpaccio /Executive Clinical Director.

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

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4