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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603011
Report Date: 08/22/2024
Date Signed: 08/23/2024 10:07:31 AM

Document Has Been Signed on 08/23/2024 10:07 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:INTEGRATED TREATMENT SERVICES IIIFACILITY NUMBER:
198603011
ADMINISTRATOR/
DIRECTOR:		AUBRI GRIFFISFACILITY TYPE:
737
ADDRESS:15331 S AINSWORTH STTELEPHONE:
(310) 916-7200
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 3CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Godspower Emuze, Lead RBTTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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On 8/23/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Mary Jiminez, Lead PT, and explained the purpose of the visit is to deliver amended findings for the allegations mentioned above. LPA was granted access to the facility.

On 8/22/24 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on an incident report faxed to CCLD on 8/8/24 and 8/16/24. LPA was greeted by staff, Godspower Emuze, Lead RBT. LPA spoke with Staff and explained the purpose of the visit was to gather information surrounding the incident with R1.

On 8/8/24, CCLD received an email from Integrated Treatment Services, III reporting that on 8/7/24, Administrator learned of an incident that involved abuse of a client by a staff member. In the course of the investigation, the Administrator learned of a separate incident on 8/9/24 in which an additional email was sent to CCLD on 8/16/24.

The following documents were requested and received during the visit:

· LIC500
· Staff file for S1
· Staff file for S2

Deficiencies were cited for this visit.

An exit interview was conducted with staff, Mary Jiminez and a hard copy of the report was provided to be given to Administrator, Aubri Griffis.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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
Document Has Been Signed on 08/23/2024 10:08 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/23/2024 09:02 AM


Created By: Felisa Shirley On 08/22/2024 at 03:55 PM
Link to Parent Document Below:
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 III
FACILITY NUMBER: 198603011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
80061(b)(E)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

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requirement is not met as evidenced by:

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Licensee shall review Rules and
Regulations re Reporting Requirements and submit to CCLD a training for all staff, signed and submit to LPA, Felisa Shirley via fax or email, to felisa.shirley@dss.ca.gov by POC correction date of 9/5/24.
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Based on interview, and record review licensee did report to CCLD within the next working day during normal business hours which poses an immediate health and safety risk to persons in care.
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Type B
09/05/2024
Section Cited
CCR80019(f)

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80019 Criminal Record Clearance
(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department:
(1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).
(2) A copy of the individual's:
(A) Driver's license, or
(B) Valid identification card issued by the Department of Motor Vehicles, or
(C) Valid photo identification issued by another state or the United States government if the individual is not a California resident.


This
requirement is not met as evidenced by:
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Licensee shall associate staff S1 and S3 to facility or remove them from the schedule and submit to LPA, Felisa Shirley via fax or email to felisa.shirley@dss.ca.gov by POC correction date of 9/5/24.
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Based on record review, on 8/22/24 LPA Shirley reviewed facility records and found that S1 and S3 are not associated to this facility which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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