191500823-3-7-2024-11-AS-SLEO-D35VQC-20240307153806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:38:14 PM

Document Has Been Signed on 03/07/2024 03:38 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 ASC, 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: 105	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator - Aaron Khodorkovsky		TIME COMPLETED:	04:00 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	On 03/7/2024 at around 9:00 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Assistant Itzia Maciel. LPA explained the purpose of the visit and was accompanied by the Administrator Assistant inside and outside the facility during this inspection. This facility is licensed to serve 106 non-ambulatory adults ages 18 – 59 years, of which 25 may be on hospice. A total of 105 clients are currently residing in this facility. The Annual Licensing Fees are current. The facility is a one-story building located on a main street. The building consists of 53 client bedrooms, 4 shower rooms, 1 industrial kitchen, several toilet rooms, 1 dining room, 2 court yards, 1 tv room, several office spaces, 1 parking lot, 1 laundry room, 1 activity room, 1 break room, and several outside seating areas.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 03/07/2024

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed this month’s meal menu.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Fire drill was conducted on 03/01/2024. First aid kit is fully stocked with manual. The facility completed their Annual Fire Inspection, Testing, & Maintenance on 07/14/2023 certified by the State of California State Fire Marshal. There are several fire extinguishers around the building. There are several videoconferencing devices (iPhones and tablets) that are dedicated for client use.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 03/07/2024

NARRATIVE

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Several client bedrooms were checked. Mattresses were in good condition, adequate lighting, dresser and closet space observed. Walls and floors were in good condition. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation and their Criminal Record Clearances.

5 client records were reviewed and, 5 out of 5 client records had their required documentation.

No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

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

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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