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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603011
Report Date: 03/29/2023
Date Signed: 03/29/2023 01:17:49 PM

Document Has Been Signed on 03/29/2023 01:17 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, 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: 3DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Aubri Griffis-AdministratorTIME COMPLETED:
01:17 PM
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On 3/29/2023 at 10:30 AM, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Aubri Griffis-Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (3) non-ambulatory, (developmentally disabled or Mentally Ill) adults ages 18 through 59. Currently, the home has (3) clients. The clients are Westside Regional Center clients. None the clients have Restricted Health Care Conditions, and (1) client is utilizing postural supports or protective devices (seizure helmet).

The Facility is a one-story family home with three (3) bedrooms, two (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 (1) 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.

LPA Iniguez and Administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F Bathroom #1 115F° & Bathroom #2 111.2F°.

Continue on LIC809C...

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INTEGRATED TREATMENT SERVICES III
FACILITY NUMBER: 198603011
VISIT DATE: 03/29/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

LPA conducted a records review of (3) client records, (5) staff records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

During today’s visit LPA did not observe any deficiencies.

Exit interview conducted with Aubri Griffs-Adminsitrator.

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

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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