191500823-4-1-2022-11-AS-UCOL-CD42JW-20220401172700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 03/22/2022
Date Signed: 04/01/2022 05:27:26 PM

Document Has Been Signed on 04/01/2022 05:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 99	DATE:	03/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Aaron Khodorkovsky		TIME COMPLETED:	03:27 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Aaron Khodorkovsky, administrator and the purpose of today’s visit was explained. The facility is licensed to serve mentally disabled adults ages 18-59. Approved for 106 non-ambulatory clients. Approved hospice waiver for 25 clients. There are currently 99 clients in placement. The facility consists of 53 bedrooms (2 clients per room) with bathroom, two men and women shower rooms, medication room, housekeeper break room, dining room, kitchen, two staff bathroom for men and women, time clock room, laundry room, cleaning supplies room, TV room, Administrator and Main office, conference room, two outside patios and a parking lot. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The water temperature measured between 110.4 and 113.1 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a supply nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2022 05:27 PM - It Cannot Be Edited

Created By: Ulysses Coronel On 03/22/2022 at 01:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above the outdoor passageway of the west wing of the facility is not in clean & sanitary condition, the floor in bedroom 22 floor is flooded and the toilet in bedroom 22 & the door in the laundry area are in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2022
	Plan of Correction
1 2 3 4	The administrator agreed to have the outdoor passageway of the west wing of the facility cleaned, the floor in bedroom 22 cleaned & dried and the toilet in bedroom 22 & the door in the laundry room repaired. The administrator will also create a plan to ensure that the facility is kept clean, safe, sanitary and in good repair at all times. Proof of corrections will be submitted by POC due date.

Type B

Section Cited

CCR

80088(b)

Fixtures, Furniture, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above the screen doors of rooms 11,13,15,17,19,20, 21 and 22 were in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2022
	Plan of Correction
1 2 3 4	The administrator agreed to have all screen doors of the west wing of the facility repaired. The administrator will also create a plan to ensure that all window screens will be in good repair . Proof of corrections will be submitted by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Ulysses Coronel

LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC809 (FAS) - (06/04)

Page: 4 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/22/2022

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit the LPA Coronel observed the following deficiencies: 1. The outdoor passageway of the west wing of the facility is not in clean and sanitary condition. The floor in bedroom 22 floor is flooded. The toilet in bedroom 22 and the door in the laundry area are in disrepair. 2. The screen doors of rooms 11,13,15,17,19,20, 21 and 22 were in disrepair. Title 22, Division 6 and Chapter 6 is being cited on attached LIC809D form.

Plans of corrections were developed and exit interview held. A copy of the report and appeals rights was provided to was provided to Aaron Khodorkovsky, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC809 (FAS) - (06/04)

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