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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 08/10/2023
Date Signed: 10/23/2023 09:15:53 AM

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
08/01/2023 and conducted by Evaluator Wendy Gibbs
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230801090144
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: 104DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Aaron KhodokovskyTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not maintain confidentiality of clients personal conversations
INVESTIGATION FINDINGS:
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On 08/10/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced complaint visit to the facility listed above. LPA Gibbs met wtih Assistant Administrator, Itzia Maciel, and explained the purpose of today's visit. We were later joined by Administrator, Aaron Khodokovsky.

During today's visit, LPA toured the famility, conducted interviews with staff and clients, and received copies of documents pertinent to the investigation. LPA reviewed and received copies of the clients personal rights, house rules and staff trining log for new hires and recent training conducted 0n 06/15/23 regarding respect of and talking to residents.


Investigation Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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-20230801090144
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: 08/10/2023
NARRATIVE
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Allegation: Staff did not maintain confidentiality of client’s personal conversation.

The allegation alleged that a client informed staff another client had something they shouldn’t and when staff confiscated the item staff told the client who told on them.

The investigation revealed the following: Upon reviewing the Personal Rights given to Clients during admission to the facility, LPA observed “Each person receiving services from a community care facility shall have rights which include: to be accorded dignity in his/her personal relationships with staff and other persons.” During interviews with staff (A1, and S1-S6), seven (7) out of seven (7) stated they would not divulge information regarding a confidential conversation, unless it was unsafe, dangerous, or threatening to themselves or others. Additionally, staff (A1, and S1-S6), seven (7) out of seven (7) stated, they would not divulge a client’s identity if they informed them of another client being unsafe, dangerous, or threatening. Staff (A1, and S1-S6) seven (7) out of seven (7) stated, they would keep the reporting Clients identity confidential. Interviews with Clients (C1-C7), seven (7) out of seven (7) clients stated, they feel comfortable going to staff and having a confidential conversation. Clients (C1-C7), seven (7) out of seven (7) stated, they feel staff ensures their privacy and confidentiality and staff would not divulge information regarding a personal conversation unless it effects the safety of the client or other clients.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2