<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 08/07/2024
Date Signed: 08/12/2024 04:04:37 PM

Document Has Been Signed on 08/12/2024 04:04 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 HOMEFACILITY NUMBER:
191500823
ADMINISTRATOR/
DIRECTOR:		AARON KHODORKOVSKYFACILITY TYPE:
735
ADDRESS:3570 E. IMPERIAL HWY.TELEPHONE:
(310) 631-7569
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 106CENSUS: 106DATE:
08/07/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator - Aaron KhodorkovskyTIME VISIT/
INSPECTION COMPLETED:
03:00 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 08/07/2024 at around 2:00 PM, an Informal meeting was held by the El Segundo Adult and Senior Care Regional Office via TEAMS (videoconferencing). Present during this meeting were Licensing Program Manager Ulysses Coronel, Licensing Program Analysts Socorro Leandro and Hollie Enriquez, Administrator Aaron Khodorkovsky, Assistant Administrator Itzia Natalia Maciel, and Licensee Representative Lary Hulsey.

The following were discussed during the meeting: Administrator Oversight & Responsibilities; Care & Supervision of Clients in Care; Resubmission of Proof of Corrections cited on 07/10/2024.



No deficiencies were cited during this meeting.

A copy of report was emailed to Administrator for signature.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1