198602267-1-19-2023-11-AS-PSCT-CN8UNJ-20230119144402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602267
Report Date: 01/19/2023
Date Signed: 01/19/2023 02:44:11 PM

Document Has Been Signed on 01/19/2023 02:44 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:	ENSLOW MANOR		FACILITY NUMBER:	198602267
ADMINISTRATOR:	KIFLEZGHIE, JOVONNE		FACILITY TYPE:	735
ADDRESS:	20015 ENSLOW DRIVE		TELEPHONE:	(310) 933-8710
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 4	DATE:	01/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Dontri Sangchampa		TIME COMPLETED:	03:00 PM

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On 01/19/23, at 1:30 pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Dontri Sangchampa, staff, and the purpose of today’s visit was explained. The facility is licensed to serve (4) Developmentally Disabled Adults ages 18 – 59 (4) non-ambulatories, and (1) approved hospice waiver. The facilities annual fees are due on 1/31/2023, and the current balance is $454.00.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were also observed. The facility has the mandated COVID infection control posters. My temperature was taken at the entrance of the facility where there is a sanitizing station and a logbook for visitors to check in.

Currently, the home has (2) ambulatory and (2) non-ambulatory clients. LPA Scott inspected the inside/outside facility grounds. The last fire drill was conducted on 9/06/22. LPA observed that all medications and records are maintained in compliance with label instructions and are inaccessible to the clients. The facility consists of (3) client bedrooms (1) client bathroom and (1) staff bathroom, living room, kitchen, dining area, office, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ENSLOW MANOR	FACILITY NUMBER: 198602267
	VISIT DATE: 01/19/2023

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LPA Scott and Ms. Sangchampa toured the facility. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for clients personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured at 106.6 degrees Fahrenheit.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and knives were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Dontri Sangchampa, staff.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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