191500823-1-31-2025-11-AS-JHAD-DDRTGA-20250210134248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 01/31/2025
Date Signed: 01/31/2025 03:50:51 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
01/29/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250129084528

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: 105	DATE:	01/31/2025
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Itzia Maciel & Aaron Khodokovsky		TIME COMPLETED:	03:11 PM

ALLEGATION(S):

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Licensee does not assist resident with arranging medical care.

INVESTIGATION FINDINGS:

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On January 31,2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) conducted an initial, unannounced complaint visit. The Administrator Aaron Khodokovsky and the Assistant Administrator Itzia Maciel greeted the Department. The Department explained that the purpose of this visit was to investigate the allegation mentioned above.

The investigation included interviews, collection of records and tour of the facility. Interviews were conducted with staff members #1 to #2 (S1-S2), resident members #1-#10 (R1-R10), and witness #1 (W1). The Department reviewed several documents, including the Personnel Report LIC 500 (dated 05/01/24), the Resident Roster (dated 01/31/25), Resident #1 (R1)'s Face Sheet; Identificaiton and Emergency Information; Service Plan; Resident Assessment; Prepalcement Appraisal Information; Admissons Agreement; Physicians Report; and Medical Insurance Plan.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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 3

Control Number 11-AS-20250129084528

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: 01/31/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Licensee does not assist resident with arranging medical care.

The details of this complaint allege that the licensee did not assist Resident #1 (R1) with arranging medical services. It is reported that (R1) has been at the facility for a few weeks and requested eyeglasses. However, the facility has failed to assist (R1) with this request. (R1) requires prescription glasses due to visual impairment, which interferes with daily tasks.

Further information indicates that Staff #1 (S1) stated that the primary physician had not authorized an appointment with an optometrist. This statement is disputed because (R1's) medical insurance does not require a referral from the primary physician. Appointments can be made directly with (R1's) optometrist or ophthalmologist without a referral.

On January 31, 2025, between 9:30 AM and 10:10 AM, the Department interviewed two staff members, Staff #1 and Staff #2, regarding an allegation they claimed was untrue. Staff #1 and #2 (S1-S2) reported that Resident #1 (R1) was recently admitted to Highland Manor Guest Home #191500823 on January 7, 2025, from Leisure Vale Assisted Living #197610442. During (R1's) resident assessment, (S1-S2) noted that (R1) did not mention having any visual impairment. According to the Physician's Report dated January 7, 2025, (R1's) physical health status indicated “visual impairment" as “No.”

(S1-S2) also stated that (R1) only informed them about needing eyeglasses after a visit with (R1's) primary care physician on January 13, 2025. During this medical office visit, (R1) did not mention any visual concerns. (S2) explained that (R1's) visit was intended for a medical evaluation of home health services and occupational therapy only.

When (S2) learned from (R1) about the need for eyeglasses, (S2) immediately contacted (R1's) primary care physician on January 17, 2025, to request a referral to an optometrist. (S2) confirmed that (R1's) medical plan requires a referral from the primary physician for this type of care.

On January 31, 2025, between 10:30 AM and 11:45 AM, the Department interviewed 9 out of 10 residents, identified as R#2 through R#10. None of the residents were able to verify the allegation made. (R2-R10) reported that the facility staff promptly assisted them with their medical, vision, and dental care. They also expressed no issues or concerns regarding their medical care services or insurance coverage.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250129084528

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: 01/31/2025

NARRATIVE

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Resident R#1 verified being recently admitted to Highland Manor Guest Home. However, (R1) could not recall notifying staff members of any visual concerns during the resident assessment. (R1) also does not remember seeing the primary physician on January 13, 2025, and is unaware of what type of medical insurance (R1) currently had or who the primary care physician is. (R1) expressed having cataract surgery approximately two years back and needing reading glasses. (R1) reported that the reading glasses were lost at the Leisure Vale facility, and the staff never assisted (R1) with replacement glasses.

On January 31, 2025, at 09:30 AM and 9:55 AM, the Department interviewed one witness, Witness #1. (W1) is a representative from (R1’s) primary care office who validated that (R1's) medical coverage required (R1’s) primary physician referral with an optometrist. (W1) indicated that (R1) 's scheduled appointment is for February 10, 2025. (W1) also verified that (R1) was last seen by the physician on an office visit on 01/13/25.

The Department reviewed Resident #1 (R1’s) Identification and Emergency Information LIC 601 (date 01/07/25); Admission Agreement (dated 01/07/25); Service Plan (dated 01/07/25); Resident Assessment (dated 01/09/25); Preplacement Appraisal Information LIC 603A (dated 01/09/25; Medical Insurance Coverage; Medical Report (dated 01/13/25), and Physician Communication Request for Optometrist Appointment (dated 01/7/25) revealed no mentioned of (R1’) visual impairment condition.

Based on the gathered information, there is insufficient evidence to support the stated allegation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted with Itzia Maciel, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC9099 (FAS) - (06/04)

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