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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602267
Report Date: 12/31/2024
Date Signed: 12/31/2024 11:45:10 AM

Document Has Been Signed on 12/31/2024 11:45 AM - 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:
12/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Jovonne Kiflezghie, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:17 AM
NARRATIVE
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On 12/31/2024 at 8:51am, LPA Zina Brown conducted an unannounced continuation annual visit. LPA met with Jovonne Kiflezghie, Administrator and the purpose of today’s visit was explained.

LPA conducted a records review of (4) client records, (4) staff records, and (4) clients Personal & Incidental Records. Some of clients & staff records were incomplete. LPA observed the following not in compliance:
  • Physicians Report and TB Test for Client #3 and Client #4
  • Physicians Report for Staff #4 (Administrator)
  • Appraisal & Needs Service Plan for Client #3

Deficiencies Cited Under California Code of Regulations Title 22, Division 6, Chapter 1.
Exit interview conducted with Jovonne Kiflezghie, Administrator and a copy of the appeal rights were given.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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 12/31/2024 11:45 AM - It Cannot Be Edited


Created By: Zina Brown On 12/31/2024 at 10:41 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ENSLOW MANOR
FACILITY NUMBER: 198602267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
80066(a)(10)(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).
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Based on observation and interview the licensee did not comply with the section cited for 1 out of 4 staffs which poses an immediate health, safety or personal rights risk to person in care.
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The adminstrator will submit a completed medical assessment by physician for Staff #4 and sent proof to the department at zina.brown@dss.ca.gov by POC Due Date.
Type A
01/31/2025
Section Cited
CCR85070(a)(3)

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(a) In addition to Section 80070, each client record must contain the following information:(3) Needs and Services Plan and any modifications thereto, as specified in Sections 80068.2, 80068.3, 85068.2 and 85068.3.
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Based on observation and interview the licensee did not comply with the section cited for 1 out of 4 clients which poses an immediate health, safety or personal rights risk to person in care.
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The adminstrator will obtain a completed IPP by regional center service coordinator for Client #3 and sent proof to the department at zina.brown@dss.ca.gov by POC Due Date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


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Document Has Been Signed on 12/31/2024 11:45 AM - It Cannot Be Edited


Created By: Zina Brown On 12/31/2024 at 11:18 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ENSLOW MANOR
FACILITY NUMBER: 198602267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2024
Section Cited
CCR
80069(c)(1)-(5)

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(b) Each record must contain information including, but not limited to, the following:(c) The medical assessment shall include the following: (1)The results of an examination for tuberculosis (2) Identification of the client's special problems and needs.
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Based on observation and interview the licensee did not comply with the section cited for 2 out of 4 clients which poses an immediate health, safety or personal rights risk to person in care.
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(3) Identification of any prescribed medications being taken by the client.
(4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). (5) Identification of physical restrictions, including diet restrictions, to determine the client's capacity to participate in the licensee's program.
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The adminstrator will submit a completed medical assessment with TB results by physician for Client #3 and Client #4 sent proof to the department at zina.brown@dss.ca.gov by POC Due Date.

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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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
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