191500823-2-15-2024-11-AS-JHAD-D2Q3LC-20240222172030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:31:57 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
02/02/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230202094331

FACILITY NAME:	HIGHLAND MANOR GUEST HOME		FACILITY NUMBER:	191500823
ADMINISTRATOR:	AARON KHODORKOVSKY		FACILITY TYPE:	735
ADDRESS:	3570 E. IMPERIAL HWY.		TELEPHONE:	(310) 631-7569
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	106	CENSUS: 106	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Itzia Maciel		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not providing resident with the correct P&I amount.

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 02/10/23. 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 P & I Ledgers 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)

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Control Number 11-AS-20230202094331

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 are not providing resident with the correct P&I amount.

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 facility is not giving the correct amount of P & I money to the client (C1). It is alleged that the client only receives $125.00 per month when (C1) should receive $168.00 per month. 2 of 2 staff denied the allegation that Staff are not providing resident with the correct P&I amount. All staff (S1-S2) stated that C1 does in fact get all the P & I (Personal and Incidental) money. All staff state that they have the P & I ledgers to prove that C1 has received all monies due. They say that once C1 has paid rent what is left is $168.00 and that is given monthly. They further state that C1 was getting another check from another agency but they soon discovered that they were overpaying C1, so they stopped any further payments to C1. The client then blamed them stated S1-S2, but they state they had nothing to do with that.

LPA reviewed the P & I ledgers and did not find any discrepancies in the record. LPA interviewed clients C2-C11, and 10 of 10 clients denied the allegation that Staff are not providing resident with the correct P&I amount. All clients stated that they do not have any problems with receiving their P & I money or getting the correct amount monthly. LPA could not interview C1 because C1 has self-discharged C1 from the facility. Staff did not have a forwarding address or phone number for C1. LPA reviewed records and could not find any relatives or additional information to get in contact with C1.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not providing resident with the correct P&I amount. 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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