191500823-5-15-2022-11-AS-MVAO-CJVRF7-20221004125834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 05/13/2022
Date Signed: 05/15/2022 05:25:14 PM

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
04/20/2020 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20200420145538

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: 103	DATE:	05/13/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	ITZIA MACIEL		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced complaint visit to the facility and was greeted and assisted by Wellness Coordinator Itzia Maciel. Administrator Aaron Khodorkovsky joined the visit via telephone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The invesitgation consisted of the following: An initial 10-Day virtual visit was conducted by LPA Lourdes Montoya on 04/27/21 (via telephonically) with Administrator (Sonny Ngiangia) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

During the virtual, video conference call with Administrator Ngiangia, LPA Montoya observed the inside and outside grounds of the facility. Facility is a single-story building with 53 shared bedrooms, a TV/Break room, and a designated outdoor smoking area in the parking lot. Facility currently has 64 clients. LPA Montoya interviewed Administrator Ngiangia and requested the following facility records: client roster, staff roster, unusual incident/injury report (LIC 624), S1's administrative leave/disciplinary action and termination records

Report continued in LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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-20200420145538

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: 05/13/2022

NARRATIVE

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C1's current IPP report, C1's hospital visit summaries, C1's photos (showing injuries), S2's written incident statement, S3's written incident statement, and the house rules. A separate investigation was conducted by Department of Social Services Investigations Branch (IB) Investigator (Edward Hector) which included a review of the facility’s surveillance video, hospital medical records, LASD incident report, and photographs; interviews with five (5) facility staff, three (3) clients, two (2) medical services staff, and the responding LASD deputies.

Allegation: Facility staff handled resident in a rough manner

Regarding Allegation #2: this investigation revealed that Staff #3 (referred to as S3) made physical contact in an escorting manner; but, it does not appear indicative of physical abuse. In addition, Client#1 (referred to as C1) advised that he almost fell, but a staff member (inconsistent in identifying the assisting staff) caught him. This action was not seen in the facility’s surveillance video. Based upon the evidence gathered and interviews conducted and records reviewed; 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 above allegation of PERSONAL RIGHTS: Facility staff handled resident in a rough manner is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report were provided to Wellness Coordinator Itzia Maciel.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC9099 (FAS) - (06/04)

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