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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 03/13/2025
Date Signed: 03/13/2025 11:23:46 AM

Document Has Been Signed on 03/13/2025 11:23 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 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:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Assistant Administrator Itzia MacielTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On 03/13/25 Licensing program analyst (LPA) Villegas conducted an unannounced required visit using the CARE Inspection Tool. LPA met with Assistant Administrator Itzia Maciel as the purpose of the visit was explained. The facility is licensed to serve 106 severe mentally disabled adults ages 18-59. The facility is approved for 106 non ambulatory clients and has an approved hospice waiver for 25 clients. Facility fees are current, liability insurance active (01/01/26).

The facility is a one-story building that 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 an outside seating areas. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. Internet and telephone service was observed. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 6 staff records, 8 client records, 8 medication administration records, and 4 P&I ledgers, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 02/12/25, 12 fire extinguisher observed throughout the facility and are fully charged , carbon monoxide and smoke detectors are operational. Official Inspection conducted by County of Los Angeles Fire department was on 11/19/24.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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