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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:32:45 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
05/18/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230518152757
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: 102DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Aaron Khodorkovsky - AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee does not ensure window screens are clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mario Leon conducted a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Aaron Khodokovsky, Administrator.

The investigation consisted of following:

LPA conducted Interviews and Record reviews. On 05/24/23, LPA Leon conducted interviews with S1-Administrator and S2 - S6. The LPA toured the facility and observed the facility. LPA toured client rooms #50, #30, #28, #25, #16, #13, #14, #12, #5, #4, #3 & #1. LPA toured the TV room, kitchen and refrigerator/freezer and the West courtyard. LPA also toured front office and the business office. LPA also requested copies of the following documents: Resident and Staff rosters, facility sketch and housekeeping log for the month of May, 2023. LPA also requested client documents from C2,C5 and C7, which included: Physician's reports, Needs and services plan and ID/Emergency info for each client. LPA interviewed C1 – C12. C2 was not on-site for interview. Eleven (11), out of twelve (12) clients denied the allegation listed above. See LIC9099C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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-20230518152757
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: 05/24/2023
NARRATIVE
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The interviews conducted did not concur with the above 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 with Aaron Khodorkovsky, Administrator, and a hard copy of this report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2