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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 04/05/2024
Date Signed: 04/05/2024 03:39:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
03/12/2024 and conducted by Evaluator Socorro Leandro
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240312112713
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:
04/05/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Assistant - Itzia MacielTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility's call button is inaccessible to clients in care.
INVESTIGATION FINDINGS:
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On 04/05/2024 at around 8:00 AM Licensing Program Analyst (LPA) Socorro Leandro continued a complaint investigation regarding the allegation listed above. LPA met with Administrator Assistant Itzia Maciel and the purpose of the visit was explained.

The investigation consisted of the following: During today’s investigation LPA, and Administrator Assistant conducted a tour of the facility which included checking random resident bedrooms. LPA interviewed 10 out of 106 clients. LPA reviewed facility sketch, resident census, personnel report, and 5 resident records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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 5
Control Number 11-AS-20240312112713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823
VISIT DATE: 04/05/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Facility's call button is inaccessible to clients in care” it is being alleged that call buttons are unreachable to clients in care. 1 out 11 client interviews indicated that their call button is inaccessible to them. LPA observed the following: Client 10 (C10) has physical disabilities and due to their disability, they are unable to reach the call button. Moreover, there is a piece of furniture blocking the passageway for C10 to reach the call button. Regarding the allegation “Facility's call button is inaccessible to clients in care,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Deficiencies cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator Assistant along with their appeal rights.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240312112713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
800729(a)(2)
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80072 Personal Rights (a) Except...each client shall have personal rights which include...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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Licensee will come up with a plan to make C10's call button accessible to him. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
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Based on interview and observation, the licensee did not comply with the section cited above in having a call button inaccessible to clients in care, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5