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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:28:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230412082850
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:
02/15/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Itzia MacielTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is not helping resident.
INVESTIGATION FINDINGS:
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On 02/15/24, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Itzia Maciel, Assistant Administrator (S1) and Administrator, Aaron Khodorkovsky (S2). LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above.

The investigation consisted of the following:

An initial complaint visit was completed by LPA Martessa Brown on 04/14/23. A subsequent visit was completed by LPA Perry Scott on 02/15/24. LPAs investigated the allegation mentioned in this complaint; and conducted interviews with clients and staff. Staff rosters, Client rosters, Physician's Reports, Appraisals/Needs and Services Plans, ID/Emergency information, and Progress Notes for client #1 (C1) were obtained from the facility. A tour of the facility was conducted.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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-20230412082850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823
VISIT DATE: 02/15/2024
NARRATIVE
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The investigation revealed the following: Allegation-Staff is not helping resident.

On 02/15/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S2) and clients (C2-C11). The details of the complaint alleged that the administrator and the social worker are not helping the client (C1) to find a new place to live. 2 of 2 staff denied the allegation that Staff is not helping resident. All staff (S1-S2) stated that they in fact helped C1 apply for eleven (11) different facilities but C1 was inpatient with the process and believed we did not want to help when in fact we were going out of our way to help C1. Staff also stated that C1 eventually found a skilled nursing facility and moved out on 12/27/23. However, C1 passed away on 01/06/24. LPA interviewed clients C2-C11, and 10 of 10 clients interviewed denied the allegation that staff is not helping resident. All clients stated that staff does help with any problems or issues that occur in the facility. Client C1 was no longer available for interview because C1 has since passed away.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff is not helping resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
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