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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500823
Report Date: 05/13/2022
Date Signed: 05/15/2022 05:24:24 PM

Substantiated


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
04/20/2020 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20200420145538
FACILITY NAME:HIGHLAND MANOR GUEST HOMEFACILITY NUMBER:
191500823
ADMINISTRATOR:VERA SCHWARTZFACILITY TYPE:
735
ADDRESS:3570 E. IMPERIAL HWY.TELEPHONE:
(310) 631-7569
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:106CENSUS: 103DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Itzia MacielTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility staff hit resident in care
Falure to seek timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced complaint visit to the facility and was greeted by Wellness Itzia Maciel. Administrator Aaron Khodorkovsky joined the visit via telephone.The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The complaint consisted of the following: An initial 10-Day virtual visit was conducted by LPA Lourdes Montoya on 04/27/20 (via telephonically) with Administrator (Sonny Ngiangia) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual, video conference call with Administrator Ngiangia, LPA Montoya observed the inside and outside grounds of the facility. Facility is a single-story building with 53 shared bedrooms, a TV/Break room, and a designated outdoor smoking area in the parking lot. Facility currently has 64 clients. LPA Montoya interviewed Administrator Ngiangia and requested the following records: client roster, staff roster, unus
ual incident/injury report (LIC 624), S1's administrative leave/disciplinary action and termination records,

Report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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 4
Control Number 11-AS-20200420145538
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: 05/13/2022
NARRATIVE
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C1's current IPP report, C1's hospital visit summaries, C1's photos (showing injuries), S2's written incident statement, S3's written incident statement, and the house rules. A separate investigation was conducted by Department of Social Services, Investigations Branch (IB) Investigator (Edward Hector) which included a review of the facility’s surveillance video, hospital medical records, LASD incident report, and photographs; interviews with five (5) facility staff, three (3) clients, two (2) medical services staff, and the responding LASD deputies.

Allegation: Facility staff hit resident in care

Regarding Allegation #1: this investigation revealed that Client #1 (referred to as C1) was a client at the facility, effective 03/10/20. IB’s review of a surveillance video obtained from the facility shows on 4/12/2020 with a timestamp of 18:59:15, S1 is seen dragging C1 out of the dimly lit room into the hallway. At timestamp 18:59:19, S1 lifts up his right leg and appears to use a downward motion to stomp C1, who is still on the floor, lying on his back. At timestamp 18:59:20, S1 then uses his right hand in a closed fist position to punch C1 who is shown to be in an upward fetal position with his back on the ground, but his legs and feet in the air. At timestamp 18:59:26, S1 is shown lifting his left leg and quickly bringing it in a downward motion toward C1. According to obtained medical records (dated 04/15/20, 04/22/20, and 04/25/20) from St. Francis Medical Center, C1 suffered a facial fracture, a closed head injury, a right rib fracture, neck sprain, and chest wall contusion from an assault by Staff #1 (referred to as S1). Based upon the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met: Staff #1 dragged, punched, and kicked Client #1 who sustained injuries including a facial fracture and rib fractures; therefore the above allegation of PHYSICAL ABUSE: Facility staff hit resident in care is found to be SUBSTANTIATED.

Allegation: Failure to seek timely medical attention


Regarding Allegation #3: this investigation revealed that the facility failed to seek timely medical attention for C1: S2 stated in a written statement that C1 requested S2 to call 911 and thirty minutes later the sheriff showed up. IB’s interview with Staff #3 (referred to as S3) indicated C1 requested S3 to call 911 but there was no indication that S3 called 911. Based upon the evidence gathered and records reviewed, a call log obtained from the Los Angeles (LA) Sheriff’s Department, Century Station shows C1 made a call to 911 on 4/12/2020 at

Report continued in LIC 9099C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20200420145538
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: 05/13/2022
NARRATIVE
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2016 which stated C1 was having difficulties with staff and fears it may escalate. There was no evidence that any facility staff made a call to the LA Sheriff’s Department or 911. Based on evidence gathered, C1 made a call to LA Sheriff’s Department, Century Station, and sought emergency assistance in fear of staff assault. There was no indication that a facility staff sought medical attention for C1. According to medical records from St. Francis Medical Center, C1 suffered a facial fracture, a closed head injury, a right rib fracture, a neck sprain, and chest wall contusion from an assault by S1. Therefore, the allegation: Failure to seek timely medical attention is found to be SUBSTANTIATED.

Regarding the allegations, “Facility staff hit resident in care”, and “Failure to seek timely medical attention”, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.

California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD/IB observed the following deficiencies and are being cited on the attached LIC 9099D and Civil Penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Wellness Coordinator Itzia Maciel.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20200420145538
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: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2022
Section Cited
CCR
80072(a)(1)(2)(3)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidence by:
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The facility investigated the case and terminated S1 (perpertrator). This deficiency has been corrected. In addition, Administrator agreed to review the cited section of Title 22 and provide training to all staff. POC will be submitted to CCLD via email to lourdes.montoya@dss.ca.gov on 5/27/2022.
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Based on the department's observations, interviews and records reviews, Staff #1 dragged, punched, and kicked Client #1 who sustained injuries including a facial fracture and rib fractures and based on evidence gathered, C1 made a call to LA Sheriff’s Department, Century Station, and sought emergency assistance in fear of staff assault. There was no indication that a facility staff sought medical attention for C1. These pose immediate safety, health and personal rights 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4