191500823-10-14-2021-11-AS-JHAD-C822VL-20211021174406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 10/14/2021
Date Signed: 10/14/2021 05:21:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/14/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210914093737

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: 84	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	04:06 PM
MET WITH:	Aaron Khodorkhovsky		TIME COMPLETED:	05:37 PM

ALLEGATION(S):

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Staff gave resident the wrong medication
Facility is unkempt

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. LPA met with Aaron Khodorkhovsky, the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 09/16/2021 LPA conducted a tour of the facility, interviewed 10 out of 84 clients and requested client records. On 09/16/2021 LPA interviewed witnesses W1 and W2. On 09/20/2021 and 09/28/2021 LPA conducted record reviews. On 09/27/2021 and 09/28/2021 LPA conducted staff interviews.

The Investigation revealed the following: Regarding the allegation: Staff gave resident the wrong medication. On 09/14/2021 the department received information that client C1 was given the wrong medication at the facility. On 09/16/2021 10 out of 10 clients interviewed denied being given wrong medications by staff. On 09/28/2021 medication staff S1 stated that “C1 took all of their meds except for one, they refused to take they medication Lactulose.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210914093737

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME	FACILITY NUMBER: 191500823
	VISIT DATE: 10/14/2021

NARRATIVE

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On 09/20/2021 record reviews indicate that the medications listed on the hospital records, physician’s report and Highland Manor Guest Homes medication administration records (MAR) are the same. The MAR indicate that C1 was given their medications as ordered by the prescribing physician. Regarding the allegation: Staff gave resident the wrong medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: Facility is unkempt. On 09/14/2021 the department received information that C1’s room was very dirty and unsafe. On 09/16/2021 6 out of 10 clients stated that staff came in daily to clean their rooms, 3 out of 10 clients stated that staff did not regularly come to clean their rooms and 1 out of 10 clients stated that staff never came in to clean their room. On 09/27/2021 S2 stated that “C1’s room was always clean, housekeeping would always go and clean their room." On 09/28/2021 S1 stated “C1 kept food in their room, I remember seeing some spoilt food and watermelon in the room I let Aaron know and he had it cleaned." On 09/28/2021 record reviews indicate that C1’s room was cleaned daily 3 weeks prior to their hospitalization. Regarding the allegation: Facility is unkempt. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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