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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005658
Report Date: 10/04/2022
Date Signed: 10/04/2022 12:25:41 PM

Document Has Been Signed on 10/04/2022 12:25 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:INTEGRATED TREATMENT SEVICES IVFACILITY NUMBER:
306005658
ADMINISTRATOR:WILSON, INGRIDFACILITY TYPE:
737
ADDRESS:12921 GILBERT STTELEPHONE:
(310) 916-7200
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 2CENSUS: 2DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Steve Barrios- Psych Tech, Josh Richardson- Day Program Instructor TIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry into facility by Steve Barrios.

At 11:35 AM, LPAs toured facility with Josh Richardson, Day Program Instructor. Facility has 1 client present during today’s visit. Facility is a 2 bedroom, 2 bathroom, single story home with a detached garage. LPAs observed a screening and sanitizing station at entrance of the facility. Facility appears clean and sanitary. All clients rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. LPAs observed facility has emergency food and water supply. Facility has a secured location for client medication and files. LPAs toured the outside grounds and observed outside visitation areas . Exit gates are unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPAs observed a 4 weeks supply of PPE. LPAs reviewed all client files and all contained required documentation including updated emergency information. All staff and clients are vaccinated for COVID-19.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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