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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602267
Report Date: 12/30/2024
Date Signed: 12/31/2024 01:17:22 PM

Document Has Been Signed on 12/31/2024 01:17 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ENSLOW MANORFACILITY NUMBER:
198602267
ADMINISTRATOR/
DIRECTOR:		KIFLEZGHIE, JOVONNEFACILITY TYPE:
735
ADDRESS:20015 ENSLOW DRIVETELEPHONE:
(310) 933-8710
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Dontri Sangchampa, DSPTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 12/30/2024 at 1:48 pm, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Dontri Sangchampa Direct Support Professional and the purpose of today’s visit was explained. The facility is licensed to operate for (4) non-ambulatory and is approved for Hospice Waiver for (1) clients. Currently, the home has (4) clients: (2) ambulatory and (2) non-ambulatory. The clients are South Central Los Angeles Regional Center clients. The facility has an annual fee with the balance of $454.00 due on January 31, 2025. LPA provided pin #296580 to the facility with the option to make facility payment online.

The facility is a one story home located in a residential neighborhood. The property consists of the following: 3 client bedrooms, 2 common bathrooms, staff office, living room, kitchen, dining room, attached garage which houses the washer and dryer and an outdoor shaded area.

LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies for the MAR at the time of visit. The last fire drill was conducted 10/22/2024.

At 1:55 pm LPA and Dontri Sangchampa (DSP)toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F (in kitchen 114.2 F, in Bathroom #1-112.5F & in Bathroom #2 105.8F).

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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
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: ENSLOW MANOR
FACILITY NUMBER: 198602267
VISIT DATE: 12/30/2024
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Under the California Code of Regulations Title 22, Division 6, Chapter 1 & 6, a technical violation was issued as the LPA did not observe a LIC 503: Health Screening for the facility administrator.

Due to time constraints LPA will continue the annual inspection at a later date. Additional deficiencies will be issued at a later date if necessary.

Exit interview conducted with Dontri Sangchampa (DSP).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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