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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:16:54 AM

Document Has Been Signed on 05/04/2023 10:16 AM - 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: 102DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Itzia Maciel-Assistant AdministratorTIME COMPLETED:
10:30 AM
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On 5/4/2023, Licensing Program Analyst, LPA Martessa Brown conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was met by Itzia Maciel Assistant Administrator and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a fax copy of the incident and death report involving the death (C1) on 4/14/2023. The Incident report stated that on 4/12/2023 (C1) was found by staff #1 (S1) at 10:00 PM, in the bed and was unresponsive. Staff #1 called 911 and the police and paramedics came out to the facility. C1 was pronounced dead. On 5/2/2023, LPA Spoke to administrator and obtained and rec’d a copy of C1's Death Certificate.

On 5/4/2023, LPA conducted an interview with Assistant Administrator. LPA attempted to interview the C1's roommate but was not available. LPA toured the physical plant. Resident bedroom was inspected and all of C1 belongings have been removed.
A copy of the following documents was provided to LPA: C1 physician report, emergency contact, mar’s list, admission agreement and staff/resident roster.

LPA did not observe deficiencies therefore no citations were issued during this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Itzia Maciel. Assistant Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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