191500823-5-22-2024-11-AS-UCOL-D7A24N-20240717170414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:06:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2024 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20240513082123

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: 106	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator Assistant Itzia Maciel		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure facility was kept free of pests

INVESTIGATION FINDINGS:

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On 05/22/2024 at around 9:40 AM Licensing Program Analyst (LPA) Leandro conducted a complaint investigation regarding the allegation listed above. LPA met with the Administrator Assistant Itzia Maciel and the purpose of the visit was explained.

The investigation consisted of the following: During today’s investigation LPA and a staff member conducted a tour of the facility which included the kitchen, snack room, and room 16. LPA interviewed 5 out of 37 staff and 2 out of 106 clients. LPA reviewed client census, personnel report, fumigation records, and 1 client’s records.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20240513082123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2024 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will declutter, deep clean, and fumigate room 16. Licensee will update Service Plans’ for clients in room 16 to include a declutter plan. Clients will only be allowed to place their personal items in their closets/drawers and not in large black plastic bags.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above in having several roaches in room 16, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Licensee will place a cleaning chart in the room and housekeeping/maintenance will sing the cleaning chart each time they clean/maintain the room. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240513082123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/22/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegation “Staff did not ensure facility was kept free of pests” it is being alleged that the facility has a roach infestation. LPA observed several small brown roaches in room 16; LPA observed roaches underneath 2 small mini-fridges and LPA moved one mini-fridge and several roaches scattered everywhere. Regarding the allegation “Staff did not ensure facility was kept free of pests,” the preponderance of the evidence standard has been met therefore the allegation is substantiated.

Deficiencies cited based on LPA observation 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 Assistant along with their appeal rights.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3