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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:44:03 PM

Document Has Been Signed on 11/02/2021 02:44 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HIGHLAND MANOR GUEST HOMEFACILITY NUMBER:
191500823
ADMINISTRATOR:AARON KHODORKOVSKYFACILITY TYPE:
735
ADDRESS:3570 E. IMPERIAL HWY.TELEPHONE:
(310) 631-7569
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 106CENSUS: 87DATE:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Aaron KhodorkovskyTIME COMPLETED:
03:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management - Deficiencies visit to document deficiencies observed during investigation of a complaint with control number 11-AS-20210914093737. LPA met with Iztia Maciel Client care coordinator and Aaron Khodorkovsky, administrator and the purpose of the visit was explained.

The administrator failed to submit written reports to the licensing agency within seven days following client C1's hospitalization's on 09/06/2021 and 09/11/2021.

Title 22 Division 6 Chapter 1 Article 6 is being cited please see LIC809D.

An exit interview was conducted and a plan of correction was developed. A copy of this report and appeals rights were provided to Aaron Khodorkovsky, administrator.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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Document Has Been Signed on 11/02/2021 02:44 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 11/02/2021 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHLAND MANOR GUEST HOME
FACILITY NUMBER: 191500823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
80061(b)(1)(D)

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80061(b)(1)(D) Reporting Requirements. Upon the occurrence, ...a report shall be made to the licensing agency ... hours. In addition, a written report...shall be submitted to the licensing agency within seven days ...event. Any injury to any client which requires medical treatment.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 80061(b)(1)(D) Reporting Requirements, proof of correction will be submitted on or before POC due date.
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The licensee failed to ensure that a written report was submitted within seven days of clients hospitalization, incident reports were not submitted for client C1's hospitalizations on 09/06/21 and 09/11/21 within seven days, which poses a potential health and safety risk to clients in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021


LIC809 (FAS) - (06/04)
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