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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320290
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:58:46 PM

Document Has Been Signed on 06/10/2024 01:58 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:INTEGRATED TREATMENT SERVICESFACILITY NUMBER:
198320290
ADMINISTRATOR/
DIRECTOR:		WILSON, INGRIDFACILITY TYPE:
735
ADDRESS:2052 WEST 77TH STREETTELEPHONE:
(323) 305-3859
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:13 AM
MET WITH:AYAI SANDRATIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 06/10/2024, Program Analyst (LPA) Antonine Richard, conducted an unannounced required 1- year visit with using the new CARE Inspection Tool. Upon arrival at the facility, LPA Richard met with staff Sandra Ajaki and spoke to Licensee Ingrid Wilson via telephone and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3), South Central Los Angeles Regional Center (SCLARC) consumers in placement.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Richard will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

Staff member Sandra and LPA Richard made a complete tour of the facility. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining room, kitchen, office area, laundry area, 3 client bedrooms, 2 bathrooms, detached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1 thru #3 are designated as the client's bedrooms.

See continued LIC 809-C on page #2
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: INTEGRATED TREATMENT SERVICES
FACILITY NUMBER: 198320290
VISIT DATE: 06/10/2024
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Continued LIC809-C page #2

Documents are posted as mandated on the wall in the facility's living room on the bulletin boards. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 117.6F degrees Fahrenheit, the telephone is working, smoke and carbon monoxide detectors were in compliance, the fire extinguisher is fully charged, medications were centrally stored, and properly locked in the dining area cabinet and records are current, ample supply of perishable and nonperishable food, adequate lights and linen supply, fire/emergency drill conducted on 05/27/24. No firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.



There were no deficiencies cited.

Exit interview conducted. A copy of the report was provided to the administrator Wilson Ingrid.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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