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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:48:28 PM

Document Has Been Signed on 09/23/2024 12:48 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
09/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Administrator Aaron Khodorkovsky TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 09/23/2024 at around 10am, Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced case management visit to the above facility. LPA met with Administrator Aaron Khodorkovsky and the purpose of the visit was explained.

Administrator toured LPA through kitchen, medication room, separate male and female common showers, and the east and west wings of the interior of the facility.

LPA interviewed two (2) clients and three (3) staff. LPA reviewed and requested copies of C1 and C2 records which included: Admission Agreement, Unusual Incident Reports, and recent Assessments/ Appraisals. Administrator to email requested documents to LPA by tomorrow 09/24/2024.

No citations were issued at the time of this visit. Copy of this report has been provided the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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