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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 07/10/2024
Date Signed: 07/10/2024 03:52:57 PM

Document Has Been Signed on 07/10/2024 03:52 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
07/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator Assistant - Itzia MacielTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 07/10/2024, Licensing Program Analyst (LPA), Leandro conducted a case management visits to document deficiencies observed during an investigation related to Complaint Control Number:11-AS-20240301152839. LPA explained the purposed of the visit to the Administrator Assistant, Itzia Maciel. Interviews conducted and records reviewed revealed that the Licensee did not prevent drugs from coming into the facility, did not enforce facility policies, and did not conduct rounds effectively to ensure that clients are not doing illegal drugs and/or smoking inside the facility. Interviews conducted, observation, and records reviewed revealed that the facility has not managed to stay in compliance with their facility policies, illegal drug use, smoking inside the facility, and California Code of Regulations Tittle 22.

Deficiencies cited based on interviews conducted, records reviewed, and observation in accordance with the California Code of Regulations, Title 22. A copy of appeal rights and this report was left with the Administrator Assistant.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/10/2024 03:52 PM - It Cannot Be Edited


Created By: Socorro Leandro On 07/10/2024 at 02:33 PM
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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
85065(b)

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Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
This requirement is not met as evidenced by:
Based on interviews conducted and records reviewed the Licensee did not
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The Facility shall hire more personnel to address illegal drug use, smoking, and alcohol use inside the facility. The Facility shall hire security guards and more caregivers. Facility will have a 24-hour security guard. Facility will conduct rounds every 1 hour and document rounds.
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prevent drugs from coming into the facility, did not enforce facility policies, and did not conduct rounds effectively to ensure that clients are not doing illegal drugs and/or smoking inside the facility. This poses a potential health & safety risk to clients in care.
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Facility will follow facility policies and conduct room searches if suspected of illegal drug use, smoking, and alcohol use.
Email proof of correction to Socorro.Leandro@dss.ca.gov & Ulysses.Coronel@dss.ca.gov by POC due date.
Type B
08/06/2024
Section Cited
CCR85064(e)

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Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
This requirement is not met as evidenced by:
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The Licensee shall hire a second administrator to ensure proper oversight 24 hours a day. There shall be an administrator on the facility premises Monday to Sunday from 6:00 AM to 9:00 PM. Send
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Based on interviews conducted, observation, and record review the facility has not managed to stay in compliance with their facility policies, illegal drug use, smoking inside the facility, and California Code of Regulations Tittle 22. This poses a potential health & safety risk to clients in care.
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Email proof of correction to Socorro.Leandro@dss.ca.gov & Ulysses.Coronel@dss.ca.gov by POC due date.
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
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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