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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:13:39 PM

Document Has Been Signed on 04/11/2023 04:13 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Aaron KhodorkovskyTIME COMPLETED:
04:15 PM
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On 4/11/23, at 10:42am, Licensing Program Analyst (LPA) Felisa Shirley and (LPM) Stephanie Cifuentes arrived to conduct an unannounced Annual Required - 1 Year Inspection and met with Administrator Aaron Khodorkovsky. LPA disclosed the purpose of the inspection was granted entry into facility by the Licensee. The current census is 102.

Walk through inspection was conducted by LPA, LPM and Licensee inside and outside to ensure that there are no health and safety hazards.

The facility consists of 53 shared bedrooms with attached half baths, men and women’s shower rooms, medication room, housekeeper break room, dining room, kitchen, two staff bathrooms, laundry room, cleaning supplies room, TV room, Administrators office, conference room, three outside patios and a parking lot.

KITCHEN: LPA and LPM observed the kitchen to be clean, sanitary and all appliances were operable. The facility has a sufficient supply of perishable and non-perishable foods. The pantry, refrigerator, and freezer were well stocked.

DINING ROOM: LPA Shirley, LPM Cifuentes and Licensee inspected the dining room and found it to be clean and all the furniture was in good working order. There were adequate number of chairs and table space for all residents in the facility.

LPA, LPM and Licensee inspected the laundry room and supply rooms, there was an ample amount of locked cleaning supplies and PPE observed. Activity storage area, linen closet and supply closet inspected and within regulation.
Continued on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/11/2023
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PATIOS: LPA, LPM and Licensee inspected three shaded patios with sufficient tables and chairs for the residents. LPA observed that there was no pool or bodies of water.

BATHROOM: LPA, LPM and licensee toured the facility bathrooms. Each half bathroom had a functioning toilet and sink. LPA and licensee inspected men and women’s shower rooms, which were clean and within title 22 regulations. The water delivered at 114 F from the sinks.

BEDROOMS: LPA and Licensee inspected the bedrooms, each room had sufficient beds for the clients with chairs, nightstands and storage space.

A review of electronic Medication Records Administration (MAR) was observed to be maintained in order and accurately. LPA reviewed Staff Personal files, and LIC 500.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.



No deficiencies issued during this visit.

An exit interview conducted with Itzia Maciel and a copy of the report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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