<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:39:57 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
09/01/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210901130523
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
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Aaron KhodorkhovskyTIME COMPLETED:
02:13 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained fall while in care .
Staff are not administering medications as prescribed.
Staff are not assisting the client with self-administration of their PRN medication.
Staff yelled at resident.
Insufficient staffing to meet residents' needs.
Staff failed to provide adequate food service.
Staff failed to provide a comfortable environment for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/02/2021 Licensing Program Analyst (LPA) Ulysses Coronel initiated a complain investigation for the allegations listed above. LPA met with Izia Maciel care coordinator and spoke to Aaron Khodorkhovsky, the facility administrator over the telephone and the purpose of the visit was explained.

The investigation consisted of the following: On 09//09/2021 LPA Coronel conducted a tour of the facility, interviewed the administrator, 2 staff and client C1 and reviewed C1’s resident records. On 09/13/2021 LPA Coronel reviewed facility and staff records. On 10/14/2021 LPA Coronel interviewed the administrator, 4 staff and 10 out of 89 clients.

The investigation revealed the following: Regarding the allegation; Resident sustained fall while in care. On 09/09/2021 C1 stated “I fell face first in the hallway outside the kitchen due to staff not cleaning a spill oatmeal, It happened in the kitchen. I did not get wounded from the fall. I did not have any falls after that incident."
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 11-AS-20210901130523
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: 11/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 09/09/2021 the administrator stated “C1 was in line to get breakfast when someone in front dropped their oatmeal on the floor, C1 tripped but staff was able to assist C1 right away. I did not write an incident report because C1 was not injured. I had C1 taken to get x-rayed. Record reviews indicate that C1 was seen by their Primary care Physician on 06/03/2021 and 06/14/2021 about left knee from slipping on oatmeal around 06/02/2021. On 06/16/2021 X-rays were interpreted from C1 no fractures were observed. On 10/14/2021 8 out of 10 clients interviewed denied sustaining falls while at the facility C2 stated “No. But if I ever do, I would tell staff about it.” 2 out of 10 stated they did sustain falls. Client C3 stated “I fell outside in the parking lot.” C4 stated “Yes, sometimes my blood pressure goes up and down.” Regarding the allegation; Resident sustained fall while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Staff are not administering medications as prescribed. On 09/09/2021 client C1 stated: "The nurse aid discontinued the medication; I would like to know why. They did not show me the discontinue order. This happened about 3 weeks ago in the evening." Staff S1 stated: “One night after the doctor made the order to discontinue the sliding scale administration of C1’s medication, C1 demanded for the caregivers to give them the medication. I told C1 over the phone that the doctor has issued a new order and discontinued it. But C1 was still upset.” On 09/09/2021 record reviews indicate that C1’s medication was discontinued as a sliding scale administration (PRN) and has given a new order to be administered twice a day before breakfast and dinner. On 10/14/2021 10 out of 10 clients interviewed confirmed that staff provided them medications as prescribed. Regarding the allegation; Staff are not administering medications as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Staff are not assisting the client with self-administration of their PRN medication. On 09/09/2021 C1 stated “Staff refused to give me Tylenol and Benadryl and I would have to buy.” S1 stated “C1 never asked me for Tylenol or Benadryl. S2 stated “I usually give it to them when they ask.” On 10/14/2021 9 out of 10 clients interviewed stated that they get helped whenever they needed nonprescription pain or cold medications. 1 out of 10 clients disagreed, C5 stated “Sometimes there are no medications when I ask.” Staff S3 stated, “Sometimes, when we run out. We'll tell administrator, then we re-stock.” Regarding the allegation; Staff are not assisting the client with self-administration of their PRN medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20210901130523
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: 11/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation; Staff yelled at resident. On 09/09/2021 Client C1 stated “Staff yelled at me around 3 weeks ago. They did not tell me their name.” On 10/14/2021 8 out of 10 clients interviewed felt good about the way they were being treated by staff, C6 stated “They are all very friendly. It almost sound like music, as if they are singing when staff are talking to you.” 2 out of 10 clients interviewed stated they felt bad about the way they were being treated by staff, C7 stated “It could be better.” Staff S1, S2 and S3 denied getting complaints from clients not being treated good at the facility. Regarding the allegation; Staff yelled at resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Insufficient staffing to meet residents' needs.
On 09/09/2021 C1 stated “Insufficient staffing staff happens 2 to 3 times a week between 3pm and 11pm, there are only 2 staff on duty. The staff stays away from their station." On 09/09/2021 record reviews indicate that the facility has 2 caregivers scheduled between 4:00pm and 12:00am 7 days a week. On 10/14/2021 7 out of 10 clients interviewed stated there was enough staff present at facility, C2 stated “The staffing is nice there are new staff here now.” 2 out of 10 clients interviewed stated there was not enough staff, C7 stated “Someone’s always on lunch.” 1 out of 10 clients said they did not know if there were enough staff. Regarding the allegation; Insufficient staffing to meet residents' needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation; Staff failed to provide adequate food service. On 09/09/2021 client C1 stated “It’s not enough we all get the same amount of food." LPA conducted a tour and observed clients eating lunch and staff offering second servings of lunches and desserts to clients. On 10/14/2021 8 out of 10 clients felt good about the food being served, C8 stated “The food is okay, the quality is Cafeteria grade. They make sure that there is enough on the plate.”, 2 out of 10 clients stated they felt bad about the food being served, client C4 stated “I buy food outside, there is not enough, and the quality is trash.” On 10/14/2021 LPA conducted a tour of the kitchen and dining area and observed that the food being served was indicated in the facility’s food menu posted. Regarding the allegation; Staff failed to provide adequate food service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20210901130523
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: 11/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation; Staff failed to provide a comfortable environment for resident. On 09/09/2021 C1 stated “The administrator allowed my roommate to annoy me. They put the AC too cold at night it gives me head colds. They placed the water dispenser farther down the hall." Staff S1 stated “C1 can be very demanding, C1 gets upset if things are not done a certain way." On 10/14/2021 9 out of 10 clients interviewed stated they felt good about their stay at this facility, C8 stated” I feel comfortable, I'll stay here as long as I need to.”, 1 out of 10 felt bad about their stay, C7 stated “It makes me feel depressed, It could be a lot more positive.” Regarding the allegation; Staff failed to provide a comfortable environment for resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
09/01/2021 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210901130523

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: DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Aaron KhodorkhovskyTIME COMPLETED:
02:13 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not ensuring resident receives dental services.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/02/2021 Licensing Program Analyst (LPA) Ulysses Coronel and LPA Gail Johnson initiated a complain investigation for the allegations listed above. LPAs met with Aaron Khodorkhovsky, the facility administrator and the purpose of the visit was explained.
The investigation consisted of the following: On 09//09/2021 LPA Coronel conducted a tour of the facility, interviewed the administrator, 2 staff and client C1 and reviewed C1’s resident records. On 09/13/2021 LPA Coronel reviewed facility and staff records. On 10/14/2021 LPA Coronel interviewed the administrator, 4 staff and 10 out of 89 clients.

The investigation revealed the following: Regarding the allegation; Facility is not ensuring resident receives dental services. On 09/09/2021 C1 stated “They have not helped me with requirements, that is why I still cannot get dental services." On 10/14/2021 5 out of 10 clients interviewed agreed that the facility was not ensuring that clients receive dental services, client C5 stated “No, my teeth hurts. They tell me I have insurance problems.“. C6 stated “I would like to see the dentist right now. I'm constantly asking them.”
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20210901130523
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: 11/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 5 out of 10 clients interviewed stated they did not know that staff were supposed to ensure that clients receive dental care, C7 stated “I didn't know we can get dental services.” Regarding the allegation; Facility is not ensuring resident receives dental services. Based on LPAs observations and interviews which were conducted the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of correction were developed and appeals rights were discussed. A copy of this report and appeals rights were provided.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20210901130523
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
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
85075(b)
1
2
3
4
5
6
7
85075(b) Health-Related Services. The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not me as evidenced by:
Based on LPA observations and interviews conducted
1
2
3
4
5
6
7
The licensee will submit plans that were developed that ensures assistance is provided to the clients in meeting their dental needs. Proof of correction will be submitted by POC due date.
8
9
10
11
12
13
14
the licensee failed develop and implement plans to provide assistance in meeting client’s dental needs. The facility failed to provide assiatance to meet C1, C5 and C6's dental needs and failed to inform clients that assistance is available in meeting dental needs which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7