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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603011
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:08:57 PM

Document Has Been Signed on 03/11/2022 03:08 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:INTEGRATED TREATMENT SERVICES IIIFACILITY NUMBER:
198603011
ADMINISTRATOR:AUBRI GRIFFISFACILITY TYPE:
737
ADDRESS:15331 S AINSWORTH STTELEPHONE:
(310) 916-7200
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 3CENSUS: 2DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Erick Ventura TIME COMPLETED:
03:00 PM
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
On 03/11/22 Licensing Program Analyst (LPA) Jade Jordan made an unannounced annual inspection with an emphasis on infection control. LPA was met by Am Lead staff Erick Ventura,
and the purpose of the visit was explained.

Upon Entry LPA was screened for Covid-19 with a written questioner, and temperature was taken.


The Facility is a one-story family home with three (3) bedrooms, two/half (2 1/2) bathrooms, living room, office, dining room, office area, family room, kitchen, pantry, breakfast area, sitting area, laundry room attached to the garage. A shaded area located in the backyard. A generator for emergency located in the backyard. The facility has a two (2) car attached garage located in the front left side of the property. There are three (3) exits located in the, living room, family room and kitchen hallway. Front yard landscape is in good condition at time of visit. Washer/Dryer appliances installed and are located in the laundry area in the garage. Bedroom Residents: There shall be no more than two clients per one bedroom. Bedrooms are equipped with one queen bed, a chest of drawers, a lamp, a chair, overhead lightning, a night stand, and TV. Bedroom staff: No bedrooms are used for awake staff. Bathrooms: Bathrooms have working toilets, wash basin, and a shower. All bathrooms were free of mold and mildew. Hotwater in bathroom # 2 measured at 115.degrees F.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INTEGRATED TREATMENT SERVICES III
FACILITY NUMBER: 198603011
VISIT DATE: 03/11/2022
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
The facility is following their mitigation plan. LPA observed a minimum of 30 day supply of PPE, which included N95 masks, gowns, face shields, surgical masks, hand sanitizer, soap, disinfectant, paper towels
trash can with lid. A daily Covid log is taken for visitors ,staff , and residents.

No deficiencies were noted during this visit.

A copy of this report was provided, and an exit interview was conducted with PM staff Jose Juarez..
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2