198320195-7-26-2024-11-AS-DESA-D7JU4R-20240726151534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320195
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:16:07 PM

Document Has Been Signed on 07/26/2024 03:16 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	AGING ETERNITY RETIREMENT HOME 2		FACILITY NUMBER:	198320195
ADMINISTRATOR:	TRAKHTENBERG, NATALYA		FACILITY TYPE:	740
ADDRESS:	2581 MILITARY AVENUE		TELEPHONE:	(818) 519-3247
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Natalya Trakhtenberg, Administrator		TIME COMPLETED:	03:40 PM

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	On 7/26/2024 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Natalya Trakhtenberg, Administrator. LPA explained the purpose of today’s visit. The facility is licensed for the age range 60 and over, approved for (6) non-ambulatory, of which (6) may be bedridden, approved hospice waiver for (3). At the time of visit the facility there were 6 residents. There is 3 hospice residents at the time of visit. Facility has 6 resident bedrooms, 7 bathrooms, a front den/sitting area, attached garage, dining room, living room, back shaded patio. LPA inspected the resident’s bedrooms are spacious and easily accommodate their furnishings. LPA inspected the back yard with a patio area and chairs. Shaded area has sufficient tables and chairs for clients and staff. LPA toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of 8 rooms were inspected. A total of 7 bathrooms were inspected. LPA inspected beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. LPA inspected bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1-#6 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F. Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 2	FACILITY NUMBER: 198320195
	VISIT DATE: 07/26/2024

NARRATIVE

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LPA inspected bath towels and wash cloths where observed stored in the hallway cupboard. Facility provides hygiene supplies to clients and LPA observed adequate supplies. LPA inspected the telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall throughout the facility. Several fully charged fire extinguisher were found throughout the facility. LPA inspected dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in kitchen. Food supply was adequately stored in kitchen refrigerator, cabinets and consists of the following: a variety of fresh and canned fruit, vegetables and meats all dated. LPA inspected dual smoke and carbon monoxide detectors are hardwired and interconnected. All were operational. LPA inspected stove burners, oven, microwave, washer, and dryer are in working order. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. LPA inspected area for medication storage is in a locked glass cabinet in living room. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to clients. LPA inspected records of staff and residents are stored in a locked closet on-site. LPA inspected the facility has books, and other recreational materials for the residents. LPA did not observe any pet or bodies of water at the facility. LPA inspected fire Clearance was approved on 04/19/2021 for 6 bedridden seniors. Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 2	FACILITY NUMBER: 198320195
	VISIT DATE: 07/26/2024

NARRATIVE

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LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.
LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. LPA inspected the kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. LPA inspected a review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) were maintained in order. LPA inspected first aid kit was checked.
Due to insufficient information available at this time, the above allegations need further investigation.

Exit interview conducted. A copy of the report was given to Precy Panlaqui, Caregiver.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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