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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005658
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:45:40 PM

Document Has Been Signed on 12/17/2024 04:45 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:INTEGRATED TREATMENT SEVICES IVFACILITY NUMBER:
306005658
ADMINISTRATOR/
DIRECTOR:		WILSON, INGRIDFACILITY TYPE:
737
ADDRESS:12921 GILBERT STTELEPHONE:
(310) 916-7200
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 2CENSUS: 2DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Aubri GriffisTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:00 PM, LPA Tea was greeted and granted entry into the facility by Assistant Administrator (AA) Aubri Griffis. Facility is licensed for 2 non-ambulatory clients. Currently there are two clients during today's visit.

At 1:15 PM, LPA Tea reviewed two client files and five staff files. Client files and staff files contained all required documentation apart from one resident who, just recently got medical insurance coverage. The staff are currently trying to obtain an updated physician’s report. AA Griffis’s certificate expires April 12, 2026.



LPA Tea along with the AA Griffis’s and Lead PT Carla Ibarra toured the facility at 2:22 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with two client bedrooms, two bathrooms, a staff office room, a vocational room, living room, laundry area, dining room, kitchen and detached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured around 110.8 degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. There are cameras in the common area, recording video with no audio for safety purposes. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in box and double locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: INTEGRATED TREATMENT SEVICES IV
FACILITY NUMBER: 306005658
VISIT DATE: 12/17/2024
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The fire extinguisher by the client bedrooms is fully charged. The facility’s last fire drill was conducted on September 26, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. There is one self-latching gate on the left side of the facility. There is also a basketball court for clients in the backyard to use. The clients like to play basketball. LPA observed emergency supplies, food and water in the garage. LPA Tea observed clients playing games in the dining room area. The staff provide activities on client’s preferences. Clients do puzzles, play video games, and do art such as diamond painting and creating holiday crafts. Staff provide cooking activities for the clients. Today clients made tamales for the holidays. The clients help with recycling and yard work. They go out on outings as well, like to the movies, going out to eat and play at the park.

At 2:41 PM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.



Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Assistant Administrator Aubri Griffs a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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