191500823-7-2-2025-11-AS-SCIS-DKFSHZ-20250811135423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:30:38 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
12/03/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20241203115428

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: 106	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	08:06 AM
MET WITH:	Itzia Natalia Maciel		TIME COMPLETED:	12:14 PM

ALLEGATION(S):

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Staff do not ensure that resident's incontinence needs are met.
Staff do not communicate with a resident's responsible party regarding resident's care.

INVESTIGATION FINDINGS:

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On July 2,2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequentl visit to gather information regarding the above allegation. LPA met with Administrator Assistant Itzia Natalia Maciel, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #8 (S1-S8) and client members #1 to #9 (C1-C9). List of documents reviewed/obtained Register of Facility Roster (dated 12/11/24 & 06/13/25), Personne Report (dated 05/2024), (C10)’s Physician’s Report LIC 624A (dated 11/06/24), Resident Appraisal LIC 603A (dated 07/16/24) Identification and Emergency Information document (dated 02/28/22), Personnel Report LIC 613 (dated 02/28/22), Admission Agreement (dated 02/28/22), and other records pertinent to this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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 4

Control Number 11-AS-20241203115428

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: 07/02/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff do not ensure that resident's incontinence needs are met.

The complaint alleges that the facility staff does not ensure Client #10 (C10) incontinence needs are met. It is reported that staff do not change (C10)’s diapers, resulting in (C10) being left in soiled diapers. No further details have been provided concerning this allegation.

A review of Client #10 (C10)'s Identification and Emergency Information document (dated 02/28/22) reveals (C10) was admitted to Highland Manor on February 28, 2022. (C10) was a client at this facility from February 28, 2022, through February 28, 2025.

On December 11, 2024, between 10:33 AM and 05:00 PM, the Department interviewed clients identified as Client #1 through Client #9 (C1-C9). Eight (8) out of the nine (9) client members reported that they had no concerns or issues with their incontinence needs. Four (4) of the nine (9) client members required assistance with incontinence care, while five (5) were independent and did not need any assistance.

On December 11, 2024, and June 13, 2025, between 10:33 AM and 05:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). Eight (8) out of the eight (8) staff members could not support this claim.

Staff members (S7 and S8) reported that the client (C10) is visually impaired but generally independent. (C10) requires some assistance, such as escort services, and is capable of self-care, including toileting, while also being aware of personal limitations. (C10) uses pull-up briefs and occasionally needs help. Clients who require assistance with incontinence receive support from care staff, who monitor their needs every two hours during shifts and (C10) was assessed and assisted.

The Department was unable to interview Client #10 (C10) on December 11, 2024, June 13, 2025, and July 2, 2025, as (C10) did not provide a contact number or forwarding address.

The Department was unable to interview the family representative of Client #10 (C10), identified as Witness #1 (W1), on June 13, 2025, and subsequent calls and text messages went unanswered on July 2, 2025.

As a result of record reviews of (C10)’s Physician’s Report LIC 624A (dated 11/06/24), and Resident Appraisal LIC 603A (dated 07/16/24), confirmed that (C10) requires assistance with activities of daily living (ADL) and can manage toileting independently.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20241203115428

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: 07/02/2025

NARRATIVE

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A further review of facility Personnel Report LIC 500 (dated 05/2024 and 03/2025) revealed no shortage of care staff for AM, PM, and NOC shifts to assist with resident’s care needs.

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

Allegation #2: Staff do not communicate with a resident's responsible party regarding resident's care.

The complaint alleges that the facility staff does not communicate with residents regarding resident’s care. It is reported that staff do not answer phone calls made to the facility by the client’s responsible party regarding Client #10 (C10). No further details have been provided concerning this allegation.

On December 11, 2024, between 10:33 AM and 05:00 PM, the Department interviewed clients identified as Client #1 through Client #9 (C1-C9). Eight (8) out of the nine (9) client members reported that they had no issues with telecommunications and could receive incoming calls or messages.

On December 11, 2024, and June 13, 2025, between 10:33 AM and 05:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). Six (6) out of the eight (8) staff members could not corroborate this claim. (S8) reported that the facility has an Interactive Voice Response (IVR) telecommunication system, which reduces wait times, provides 24/7 availability, improves efficiency, and facilitates better call routing for incoming calls.

A staff member (S1) reported that the family representative for (C10), referred to as Witness #1 (W1), communicated with (S1) about issues with the house phone, which was not functioning correctly. On one occasion, (W1) attempted to call and was connected to (C10), who chose not to take the call. (W1) was provided with the direct phone numbers for (S1), (S7), and (S8) in case (W1) wanted to make a follow-up call to (C10).

The Department was unable to interview Client #10 (C10) on December 11, 2024, June 13, 2025, and July 2, 2025, as (C10) did not provide a contact number or forwarding address.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20241203115428

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: 07/02/2025

NARRATIVE

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As a result of reviewing the records of (C10)’s Admission Agreement (dated 02/28/22) and Personal Right LIC 613 (dated 02/28/22), it was revealed that the facility is operating within licensing regulatory compliance.

During the visit on July 2, 2025, the Department identified that the facility promotes the rights of its clients. To improve the environment, posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

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

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegations are Unsubstantiated.

An exit interview conducted with Administrator Assistant Itzia Natalia Maciel and copies of the report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

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