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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 01/25/2023
Date Signed: 01/25/2023 05:31:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230117162826
FACILITY NAME:HIGHLAND MANOR GUEST HOMEFACILITY NUMBER:
191500823
ADMINISTRATOR:AARON KHODORKOVSKYFACILITY TYPE:
735
ADDRESS:3570 E. IMPERIAL HWY.TELEPHONE:
(310) 631-7569
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:106CENSUS: 106DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Itzia Maciel-Social Service CoordinatorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not adequately supervising resident
INVESTIGATION FINDINGS:
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On 1/25/23 Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced initial complaint visit at this facility. LPA conducted a Covid-19 risk assessment via telephone with Aaron Khodorkovsky and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegation listed above.

The investigation consisted of the following: on 1/25/23, LPA Brown conducted a tour of facility and obtained LIC 500 and resident roster. LPA requested and received the following documents: Incident reports pertaining to the above allegation, Admissions agreements and physicians’ assessments for clients (C1-C2), mars and police report. LPA interviewed clients C1-C10 and staff S1-S5.

Investigation revealed the following:


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20230117162826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823
VISIT DATE: 01/25/2023
NARRATIVE
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Staff are not adequately supervising resident

It was alleged that the staff are not adequately supervising resident. On 1/25/23. LPA interviewed C1 regarding above allegation when client was asked questions and would not stay on topic. Interviews with C2-C10, all clients stated staff supervises them fine and had no concerns. Clients also stated they can leave and come in the facility as pleased. Interviews with S1-S5, regarding above allegation. All 5 staff stated, clients are provided adequate supervision and had no concerns. Staff stated clients can also leave and come in the facility as pleased. Staff stated if clients are missing from the facility, they will notify administrator and police reports are made. LPA reviewed C1-C2 file and residents are able to leave facility unassisted. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Based on information gathered, the department did not find sufficient evidence to support allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.



An exit interview was conducted, and a copy of this report left with Itzia Maciel-Social Service Coordinator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2