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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 04/11/2024
Date Signed: 04/11/2024 11:44:13 AM

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
03/01/2024 and conducted by Evaluator Socorro Leandro
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240301152839
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:
04/11/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Assistant - Itzia MacielTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not keeping the facility grounds clean
INVESTIGATION FINDINGS:
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On 04/11/2024 at around 8:00 AM Licensing Program Analyst (LPA) 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 outside patios. LPA interviewed 4 out of 106 clients. LPA reviewed facility sketch, resident census, personnel report, invoices for pest control, surety bond, and 5 client records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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-20240301152839
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: 04/11/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Staff are not keeping the facility grounds clean” it is being alleged that there is pigeon poop on residents’ window screens, outside patios, and on the soda machines. On 04/11/2024 LPA Leandro observed bird feces and feathers on resident windows. LPA also observed bird feces on outside patios, for example on the floors, walls, furniture, and soda machines. Regarding the allegation “Staff are not keeping the facility grounds clean,” 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: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240301152839
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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
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The facility will create a plan to clean client windows at least every two weeks and clean outside patio areas each day. Licensee will place do not feed birds signs on each outside patio. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
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Based on observation, the licensee did not comply with the section cited above in having bird feces on outside patio floors, walls, soda machines, and windows, 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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5