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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 08/20/2025
Date Signed: 08/20/2025 10:06:22 AM

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
04/23/2025 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 11-AS-20250423095431
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:
08/20/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Aaron Khodorkovsky-Administrator TIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
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9
Staff do not distribute resident's medication as prescribed.
INVESTIGATION FINDINGS:
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On 8/20/2025, at 8:55 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Aaron Khodorkovsky-Administrator who was informed of the purpose of the visit.

The investigation consisted of the following:

On 4/30/2025 at 1:30 PM, LPA Allen obtained and reviewed files for Resident 1 (R1). The file included: face sheet, Admissions agreements dated 9/8/2023, 1/1/2024, and 1/1/2025, Medication administration records (MARs) for the month of April 2025 and the administration log from March 1, 2025, to April 29, 2025, an appraisal dated 1/8/2024, resident personal property records dated 11/13/2024, staff and resident roster dated 3/2025, physician's report dated 11/13/2024, resident appraisal dated 1/8/2024, Interviews with Staff members 1-5 (S1-S5) and residents 1-8 (R1-R8).
Continued .....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 2
Control Number 11-AS-20250423095431
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: 08/20/2025
NARRATIVE
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Investigation revealed the following:

#1- Allegation: Staff do not distribute resident's medication as prescribed.

On 4/30/2025, at 1:45 PM, LPA Allen conducted interviews with Staff 1 - 5 (S1– S5) of the 5 staff members interviewed 4 out 5 stated that residents are given their medications as prescribed by their physicians. Staff also reported R1 was reassured on several occasions that all of their medications have been administered as directed. LPA attempted to interview Staff 4 (S4); however, S4 was unavailable at the time of visits and calls.

LPA also conducted interviewed Residents 1 - 8 (R1–R8) Of the eight (8) residents interviewed seven (7) stated their medications are given to them daily however, some residents reported that there are occasions when PRN medications are required after the Medtechs have left for the day. In such cases, there can be a delay in accessing the medications, resulting in a wait time of approximately 10 to 15 minutes. R1 stated their medications are given during the week but denied getting one (1) their medications on the weekend.

LPA also observed R1’s medication administration records (MAR’s) dated April 2025 and March 1,2025- April 29,2025 which appears that R1 has been given all of their medications as prescribed by their physicians. A random audit was conducted of four additional residents' MARs, and the observations revealed that Residents 9-12 (R9- R12) also appear to have been given their medications as prescribed by their physicians. During the investigation LPA observed residents receiving medications by certified medtecs S1 and S2.

Based on the evidence gathered during interviews, records review, and observations made during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted where this report was discussed and provided to Aaron Khodorkovsky- Administrator at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2