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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 10/14/2021
Date Signed: 10/14/2021 05:18:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/08/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211008123358
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: 89DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Aaron KhodorkovskyTIME COMPLETED:
04:06 PM
ALLEGATION(S):
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Resident sustained unexplained fractures while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. LPA met with Aaron Khodorkovsky, administrator and the purpose of the visit was explained.

The investigation consisted of the following: During today’s visit LPA and administrator conducted a tour of the facility. LPA interviewed administrator, 4 staff and 10 out of 89 clients . LPA reviewed client C1's records.

The investigation revealed the following: During todays visit LPA observed client C1 walking unassisted in the facility hallways. During the interview Client C1 stated that they fell in the parking lot, and denied being physically abused or neglected. Staff S1 stated "On 10/07/2021 around 2PM, I saw C1 sitting the TV room, in a crunched position while holding on to their right side. I immidiately told S2 and S2 did an assessment." S2 stated "C1 told me their shoulder was hurt and pointed towards the parking lot, I seen that his feet were swollen. C1 was taken to the hospital that same day."
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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-20211008123358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823
VISIT DATE: 10/14/2021
NARRATIVE
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Medical record reviews indicate that on 10/07/2021 C1 was noted with tendersness to the right upper rib area but was not in acute distress C1 was discharged from the hospital on 10/11/2021 with orders for Home Health physical theraphy. Regarding the allegation: Resident sustained unexplained fractures while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2