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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005658
Report Date: 01/12/2024
Date Signed: 01/12/2024 12:17:08 PM

Document Has Been Signed on 01/12/2024 12:17 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
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:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carla IbarTIME COMPLETED:
12:30 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Carla Ibarra and discussed the purpose of the inspection. Administrator (AD) Ingrid Wilson appeared via telephone.

LPA reviewed Infection Control requirements. At about 9:45AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 2-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 1 client present at the facility. Client Bedrooms: the 2 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at between 106 and 109 degrees F in the common client bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 10:45AM, LPA reviewed 2 client files and 3 staff files, interviewed 1 client and 1 staff, and inspected medications for 2 clients. The facility does not handle client money.

During the inspection, LPA and S1 observed the following: based on documents, S2 is not background cleared and has been working at the facility since 09/09/23. During the inspection, the licensee removed S2 and confirmed S2 will not return until they are background cleared and associated and LPA confirmed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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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Document Has Been Signed on 01/12/2024 12:17 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/12/2024 at 11:43 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: INTEGRATED TREATMENT SEVICES IV
FACILITY NUMBER: 306005658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, S2 is not background cleared and has been working at the facility since 09/09/23, which poses an immediate safety risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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During the inspection, the licensee removed S2 and confirmed S2 will not return until they are background cleared and associated and LPA confirmed. CIVIL PENALTIES ASSESSED. POC CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: INTEGRATED TREATMENT SEVICES IV
FACILITY NUMBER: 306005658
VISIT DATE: 01/12/2024
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties in the amount of $500 are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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