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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320195
Report Date: 02/01/2022
Date Signed: 02/02/2022 07:24:15 AM

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
MONTERY PARK, CA 91754
FACILITY NAME:AGING ETERNITY RETIREMENT HOME 2FACILITY NUMBER:
198320195
ADMINISTRATOR:TRAKHTENBERG, NATALYAFACILITY TYPE:
740
ADDRESS:2581 MILITARY AVENUETELEPHONE:
(818) 519-3247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:6CENSUS: 5DATE:
02/01/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:SERGUEI KALISTRATOVTIME COMPLETED:
12:37 PM
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On 02/01/22 Licensing Program Analyst( LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Serguei Kalistratov Licensee. LPA explained the purpose of this visit is to gather information regarding an existing complaint about Military House complaint number 11-AS-20190501100309,

The visit consisted of an interview with the licensee and staff #1 (S1). who was an active employee during the time resident #1 (R1) was residing at Military House in 2019. The licensee states (R1) did not transfer to his facility when he was licensed on 07/26/21. (S1) claims (R1) had transferred to a skilled nursing facility and did not know the name. Details on the interview are documented on LIC 812 crossed reference with Military House #197608158.

During the visit, LPA conducted a health and safety inspection and obtain a copy of the resident and staff roster. The administrator Natalya Trakhtenberg was not available during the visit. However, was available during a telephone call.

No deficiencies cited during this visit.

An exit interview was conducted with Serguei Kalistratov, and a hard copy by email.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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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