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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320220
Report Date: 10/21/2021
Date Signed: 10/21/2021 10:04:47 AM

Document Has Been Signed on 10/21/2021 10:04 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRIDGES TO RECOVERY - MAPLE DRIVEFACILITY NUMBER:
198320220
ADMINISTRATOR:SMITH, MELISSA LCSWFACILITY TYPE:
772
ADDRESS:721 MAPLE DRIVETELEPHONE:
(310) 275-4620
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90210
CAPACITY: 6CENSUS: 0DATE:
10/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Melissa Smith TIME COMPLETED:
10:15 AM
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) Troy Agard conducted an announced visit to the above facility for purpose of a pre-licensing evaluation / Change in location. LPA met with Administrator, Melissa Smith and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location.

An application was submitted to Community Care Licensing Division (CCLD) on 05/11/2021 for a change in location for a Social Rehabilitation Facility. The total requested capacity is for 6 clients. Facility has a fire clearance dated on 10/08/2021 for 6 ambulatory clients only.

Structure: Facility is a 2-story house with basement. The facility has 5 client-bedrooms, (1 shared master for 2 clients, 4 single rooms). Basement has a media room (with evacuation exit), utility closet and laundry room (with evacuation exit). 1st floor contains a foyer, 4 baths, living room, dining room, staff office, kitchen, chef’s kitchen, 2 group rooms, 1 therapy room, a covered patio and a 2-car garage converted into a fitness center. 2nd floor contains 5 bedrooms, 1 office, 6 baths, linen, laundry nook and storage closets. The master suite has a gated balcony. The 2nd floor bedroom in the rear has an evacuation exit. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard with 2 shaded patio area and chairs. There is an additional sitting area on the front lawn. Shaded areas have sufficient tables and chairs for clients. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Facility has a pool house with one bathroom that is used as an Administrative space.

Bedrooms: All 5 client bedrooms have a chair, night stands, over-head lighting, dressers and/or closets. The closets and drawers comply with the requirement of 8 cubic feet of space.


Continued on 809C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIDGES TO RECOVERY - MAPLE DRIVE
FACILITY NUMBER: 198320220
VISIT DATE: 10/21/2021
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
26
27
28
29
30
31
32
Office: Facility has 2 offices inside the main house and a pool house used as an administrative space with desk, chairs and cabinets. Staff records and client records are maintained on a digital databased. 1st office is located near the front door upon entry to foyer. 2nd office is located to the right of staircase landing, adjacent to client bedroom.

Bathrooms: Facility has 12 bathrooms (including pool house). All bathrooms where observed to have a working toilet, and wash basin. All full baths were observed to have working showers and/or bathtub.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash cloths where observed stored in the hallway cupboard. Facility provides hygiene supplies to clients and LPA observed an adequate supply.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" was observed posted in foyer. LPA observed 8 fully charged fire extinguishers throughout the facility.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the locked chef’s kitchen. Food supply was adequately stored in kitchen refrigerator, cabinets and pantry.

Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Some detectors are connected to the ADT alarm system which will notify the fire department in the event of a fire.

Appliances: Stove burners, oven, microwave, washer, and dryer are in working order. Laundry room is locked and accessible to staff only. There is a large refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.



Toxins: Locked/stored in downstairs laundry room.

Continued on 809C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRIDGES TO RECOVERY - MAPLE DRIVE
FACILITY NUMBER: 198320220
VISIT DATE: 10/21/2021
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
26
27
28
29
30
31
32
Medications, First-Aid Kit & Book: Area for medication storage is in a cabinet in the staff office. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients.

Clients & Staff Files: Records of clients are stored digitally on a databased called “Kipu and for staff on Emplicity ”

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the client's use as well as a media room/theater.

Pool/Jacuzzi & Pets: LPA observed a pool and jacuzzi that is gated, padlocked and inaccessible to clients without supervision. No pets observed.

Fire clearance: Fire Clearance was approved on 10/08/2021 for 6 ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.

Component III: Conducted at the Pre-Licensing visit, on 10/21/2021 at BRIDGES TO RECOVERY - MAPLE DRIVE. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3