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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320196
Report Date: 06/04/2021
Date Signed: 06/04/2021 05:07:29 PM

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
MONTEREY PARK, CA 91754
FACILITY NAME:AGING ETERNITY RETIREMENT HOME 1FACILITY NUMBER:
198320196
ADMINISTRATOR:TRAKHTENBERG, NATALYAFACILITY TYPE:
740
ADDRESS:2572 S. BENTLEY AVETELEPHONE:
(818) 519-3247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:6CENSUS: 4DATE:
06/04/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Natalya TrakhtenbergTIME COMPLETED:
04:00 PM
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On 06/04/2021, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced Health and Safety visit. Upon arrival at the facility, LPA Agard called and spoke with Administrator Natalya Trakhtenberg to conduct a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

During the visit, LPA Agard was informed that the facility licensee abandon facility and lost control of property in November of 2020, which deems the facility as unlicensed. Facility lease was transferred to Administrator and CCLD was not notified. Administrator has assumed responsibility of overseeing the property and currently has a pending application with CCLD. A notice of violation was served, and LPA scheduled a non-compliance meeting for Wednesday, June 9, 2021 at 2pm.

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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