191500823-11-29-2021-11-AS-MVAO-C99UP3-20211130144450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 10/07/2021
Date Signed: 11/29/2021 09:14:16 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2020 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201026160903

FACILITY NAME:	HIGHLAND MANOR GUEST HOME		FACILITY NUMBER:	191500823
ADMINISTRATOR:	VERA SCHWARTZ		FACILITY TYPE:	735
ADDRESS:	3570 E. IMPERIAL HWY.		TELEPHONE:	(310) 631-7569
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY:	106	CENSUS: 86	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Aaron Khodorkovsky - Administrator		TIME COMPLETED:	03:04 PM

ALLEGATION(S):

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Facility is in disrepair
Facility staff failed to provide a safe environment for the residents
Facility staff failed to administer residents' medication in a timely manner

INVESTIGATION FINDINGS:

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**This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created on 11/22/2021.**

On 10/07/2021 Licensing Program Analyst (LPA), Don Senaha conducted a subsequent visit to deliver complaint findings. LPA met with Administrator Aaron Khodokovsky and explained the purpose of the visit.
On 10/28/20 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via zoom with Aaron Khodokovsky/Administrator.
The investigation consisted of the following: Interviews were conducted with Administrator Aaron Khodokovsky, staff (S1-S4) and clients (C1-C10). Copies of staff roster, resident roster, facility sketch and medication administration records (MARs) were obtained. A plant inspection of the facility was conducted on 10/28/20 and 10/07/2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20201026160903

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 10/07/2021

NARRATIVE

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**This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created on 11/22/2021.**

Investigation revealed:

Allegation: Facility is in disrepair.

Clients (C1-C9) stated the facility is not in disrepair and has no issues with the facility. Client (C8) stated they fixed everything. Staff (S1-S4) stated there are no issues with the facility being in disrepair. Staff (S4) stated the facility has spent a lot of money on remodeled rooms and added TVs recently for improvements. LPA did not observe any construction or renovation going on at the time of the visit on 10/07/2021. Administrator did state they renovated the flooring and painted last year. Administrator did state the previous activity room is now used as a staff room and office and the current activity room is shared with the dining room with no construction done to these areas. LPA received the most updated facility sketch to confirm these changes. LPA did not observe any part of the facility in disrepair during the plant inspections.

Based on the interviews conducted and observations, LPA was unable to find evidence to support the allegation.

Allegation: Facility staff failed to provide a safe environment for the residents.

Clients (C1-C10) stated they feel the facility does offer a safe environment for all residents. Client (C1) stated there is always someone to help at the facility. Staff (S1-S4) stated they feel the facility provides a safe environment for the residents. Staff (S4) stated there is a security guard and the care givers are mostly males due to the clienteles which makes it feel safer. LPA did observe a security as you enter the building when you check in on 10/28/2020. LPA did observe an employee at the entrance to screen any person entering the facility on 10/07/2021. LPA did observe a canopy to provide shade to the residents that is held down by cement beams and cannot fly away in the main patio area. LPA did not observe any bedridden clients during the plant inspections. Administrator states they do not have any bedridden clients at the facility.

Based on the interviews conducted and observations, LPA was unable to find evidence to support the allegation.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20201026160903

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 10/07/2021

NARRATIVE

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**This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created on 11/22/2021.**

Allegation: Facility staff failed to administer residents’ medication in a timely manner.

Clients (C1-C10) stated they have never had an issue with staff ever missing giving them medication in a timely manner. Client (C1, C4-C10) stated they always get their mediation on time. Staff (S1-S4) stated they follow the procedure to deliver medications in a timely manner. Staff (S1) stated they hold the medications if the client missed the medication until they can find the client and if the client does not show up then they discard it properly, notify the doctor and log it on the MARs. LPA reviewed MARs for client C2, C11-C14) August-November 2020 and did not find issue with the resident’s receiving their medication in a timely manner. LPA visited medication rooms during plant inspection on 10/07/2021 and observed medications prepared to be administered in a timely manner for each client for the day.

Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated

An exit interview was conducted with Aaron Khodokovsky and a hard copy was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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