191500823-6-12-2023-11-AS-UCOL-CZ4PPV-20240102103008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 06/12/2023
Date Signed: 06/12/2023 03:02:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
06/08/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230608100954

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: 102	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Aaron Khodorkovsky - Administrator		TIME COMPLETED:	03:32 PM

ALLEGATION(S):

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Facility staff left client in urine soaked clothing for an extended period of time
Facility staff did not seek medical attention for resident
Facility staff did not safeguard residents’ belongings
Staff are not providing adequate laundry services for resident

INVESTIGATION FINDINGS:

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On 06/12/2023, Licensing program Analyst (LPA) Mario Leon conducted an unannounced complaint visit to the above listed facility. LPA was met by Aaron Khodorkovsky - Administrator, who was informed that this visit was to conduct an investigation of the above mentioned complaint allegations
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The investigation consisted of the following:

LPA toured the facility and interviewed 10 (ten) out of 102 (one-hundred and two) residents, 4 (four) staff and 2 (two) witnesses. LPA requested and reviewed resident records which consisted of: Medical assessment, Doctor's visit, admission agreement, house rules and laundry roster.

Report continues, see LIC9099C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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-20230608100954

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 06/12/2023

NARRATIVE

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Regarding the allegation: "Facility staff left client in urine soaked clothing for an extended period of time":

The records review, all four (4) staff interviews and eight (8) out of ten (10) client interviews conducted did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: "Facility staff did not seek medical attention for resident":

The records review, all four (4) staff interviews and nine (9) out of ten (10) client interviews conducted did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: "Facility staff did not safeguard residents’ belongings":

The records review, all four (4) staff interviews and eight (8) out of ten (10) client interviews conducted did not concur with the above allegation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: "Staff are not providing adequate laundry services for resident":

An exit interview was conducted with Aaron Khodorkovsky, Administrator, and a hard copy of this report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

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