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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:44:15 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, 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
05/12/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250512113202
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:
05/21/2025
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Itzia MacielTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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STAFF PHYSICALLY ASSAULTED A CLIENT.
INVESTIGATION FINDINGS:
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On 05/21/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Assistant Administrator Itzia Maciel and the purpose of the visit was explained.

Investigation consisted of the following: On 05/21/25, LPA reviewed client roster, staff roster (dated 05/2024), police report (T-281), video surveillance (05/07/25), Client #1’s record, Staff #1’s record, facility documents, toured relevant parts of the facility and interviewed Staff (S3 – S8) and Clients (C1 – C8). S1 was unavailable to conduct a telephone interview at the moment.

Investigation revealed the following:
Regarding the allegation, “staff physically assaulted client,” it is being alleged that Staff #1 (S1) and Client #1 (C1) got into a physical altercation. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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-20250512113202
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: 05/21/2025
NARRATIVE
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Video Surveillance revealed that around 5:47 PM, C1 enters the kitchen, approaches S1, and S1 pushes C1 towards the exit. S1 and C1 argues near the exit. Around 5:48 PM, S2 and S3 enters the camera frame and C1 pushes S2. Around 5:49 PM, C1 leaves the kitchen. Record review of Counseling/Disciplinary/Termination Notice (05/08/25) revealed S1’s employment was suspended due to the alleged incident of patient abuse and unprofessional conducted. It included a statement that family trespassing occurred, and they are not allowed to enter the facility without invitation and work-related reason. Notice to Employee as to Change in Relationship revealed S1 was terminated on 05/14/25. Five out of six staff interviews indicated they did not witness the physical altercation. Interview with S3 indicated that C1 was not supposed to be in the kitchen, C1 got in S1’s face, and S1 pushed C1. Seven out of eight client interviews indicated they did not witness the physical altercation. Interview with C1 indicated that C1 entered the kitchen to talk, S1 pushed C1 twice, and C1 slapped S1 back. C1 indicated that S1 followed C1 around the facility, S1 knocked off items on C1’s nightstand onto the floor, S1 smacked a phone out of C1’s hand, and called S1’s family members to the facility. Interview with C2 confirmed that S1 knocked over C1 nightstand items. Interview with C3 and S8 witnessed S1’s family members enter into the facility. S8 indicated that S1’s family members walked through the hallways looking for C1 and then waited outside for about 30 - 60 minutes.

Based on LPAs observation of the video surveillance, record review, and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights were provided to the Assistant Administrator Itzia Maciel.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250512113202
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(a) Except for children’s residential...(3) To be free from corporal or unusual punishment, infliction of pain...functioning.

This requirement was not met as evidence by:
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 Administrator agreed to develope a plan that shall ensure clients will be free from corporal and unusual punishment. POC shall be submited via email by due date to: regina.cloyd@dss.ca.gov
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Based on observations, interviews and records reviewed the licensee did not ensure that clients are free from corporal or unusual punishment. On 05/07/2025 (S1) pushed (C1) during an altercation. This 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: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
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