198320196-7-9-2021-11-AS-TAGD-C4RU2Y-20210709151243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320196
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:14:10 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 1		FACILITY NUMBER:	198320196
ADMINISTRATOR:	TRAKHTENBERG, NATALYA		FACILITY TYPE:	740
ADDRESS:	2572 S. BENTLEY AVE		TELEPHONE:	(818) 519-3247
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 4	DATE:	07/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Natalya Trakhtenberg		TIME COMPLETED:	10:20 AM

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	Licensing Program Analyst (LPA) Troy Agard conducted an announced visit to the above facility for purpose of a pre-licensing evaluation for a change in ownership. During the inspection LPA toured the inside and outside of the facility and verified the address of the location. An application was submitted to CCLD on 01/08/2021 for a change of ownership for a Residential Care Facility for the Elderly (RCFE) to serve seniors, ages 60 years plus. The requested capacity is for 6 bedridden seniors. Facility has a fire clearance for 6 bedridden residents. Structure: Facility has 8 rooms in total of which 6 are resident bedrooms (singles), a front den / sitting area, attached garage, dining room, living room, back shaded patio one-story house. The resident’s bedrooms are spacious and easily accommodate their furnishings. There is a back yard with a shaded patio area and chairs. Shaded area has sufficient tables and chairs for clients and staff. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms: All residents’ bedrooms have the appropriate furnishings for each room. Bed are fitted with full length bedrails. The closets and drawers comply with the requirement of 8 cubic feet of space. Office: Facility has an office with a desk, chairs and cabinets with staff and client records. Bathrooms: Facility has 7 full bathrooms. All bathrooms where observed to have a working toilet, wash basin and shower. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. More than adequate supply of linen; sheets, pillowcases, hand towels, Continued on 809C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 1	FACILITY NUMBER: 198320196
	VISIT DATE: 07/09/2021

NARRATIVE

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bath towels and wash cloths where observed stored in the hallway cupboard. Facility provides hygiene supplies to clients and LPA observed adequate supplies.

Emergency Phone Numbers, Exit Plan & Menu: 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 was found throughout the facility.

Food Service: 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 overflow in garage and consists of the following: a variety of fresh and canned fruit, vegetables and meats all dated.

Smoke Detectors: Dual smoke and carbon monoxide detectors are hardwired and interconnected. All were operational.

Appliances: 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.

Toxins: Locked/stored in garage

Medications, First-Aid Kit & Book: Area for medication storage is in a locked glass cabinet in the staff office. 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.

Clients & Staff Files: Records of staff and clients are stored in cabinets in staff office.

Reading Material, Games, Equipment & Materials: The facility has books, and other recreational materials for the residents.

Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility.
Continued on 809C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 1	FACILITY NUMBER: 198320196
	VISIT DATE: 07/09/2021

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Fire clearance: Fire Clearance was approved on 04/19/2021 for 6 bedridden seniors. 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.

Component III: Conducted at the Pre-Licensing visit, on 07092021 at AGING ETERNITY RETIREMENT HOME 1. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant with signature.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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