198320196-10-30-2023-11-AS-EMAZ-CYA26S-20231206160736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320196
Report Date: 02/15/2023
Date Signed: 10/30/2023 09:49:35 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
02/07/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230207101222

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:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	ADMINISTRATOR NATALYA TRAKHTENBERG		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not allow resident to choose health care provider.
Facility staff illegally evicted resident from the facility.

INVESTIGATION FINDINGS:

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A subsequent visit was conducted today by LPA Jose Calderon to add additional information not included on the initial report dated 2/15/23. The findings have not changed.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Aging Eternity Retirement Home 1 facility on 02/15/2023 and was greeted by Administrator Natalya Trakhtenberg (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Investigation consisted of: LPA Calderon interviewed Administrator Natalya Trakhtenberg A1, S1-S2 and attempted to interview R1-R4. These interviews were conducted on 02/15/2023. On 02/15/2023 LPA Calderon obtained and reviewed the following: Admission agreement (dated 12/06/2022), Physician Report (dated 12/16/2022), Journey Hospice report (dated 12/16/2022) for R1. On 03/22/2023, 03/29/2023, 04/11/2023 and 05/25/2023 requested from resident family copy of admission agreement, proof of payment, other family witness and options facility gave for hospice care. No response was received from R1’s family member.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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 3

Control Number 11-AS-20230207101222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 1	FACILITY NUMBER: 198320196
	VISIT DATE: 02/15/2023

NARRATIVE

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Regarding Allegation #1: Facility staff did not allow resident to choose health care provider.

This complaint alleged facility did not allow resident to choose hospice provider. LPA Calderon conducted an interview with A1. A1 expressed that R1 entered the facility with Kaiser hospice care, but R1 family was not happy with the hospice care being provided. A1 expressed that if a resident does not have hospice care company 3 options are given to resident family. A1 expressed that the facility will not offer any discounts to use a specific hospice company the facility works with. A1 expressed that R1 was in the facility for one month and then changed hospice agencies. A1 expressed that the R1 family gave no reason why they wanted to change hospice agencies. LPA Calderon conducted an interview with S1 who states that at no time does the facility suggest or offer any specific hospice agencies for any resident family to use. S1 expressed that R1 family was given 3 hospice options Journey Hospice, Complete Care Hospice and End Care Hospice that the facility does business with, but S1 expressed that at no time did staff advise R1 family they would have to use any specific hospice company the facility works with. LPA Calderon conducted an interview with S2 who expressed that R1 family advised S2 that R1 family was very happy with facility services and hospice services and never complained to S2 regarding care. S2 expressed that S2 was surprised that R1 left the facility after 1 month. On 02/15/2023 LPA Calderon attempted to interview R1 for complaint, but R1 no longer at facility and passed away on 02/07/2023. On 02/15/2023 LPA Calderon attempted to interview R2-R5 for complaint. 4 out of 4 residents have health conditions and could not answer questions. On 02/15/2023 LPA Calderon reviewed facility paperwork for R1. LPA Calderon reviewed admission agreement (dated 12/06/2022), there is no mention of any specific hospice company that W1 would have to use. LPA Calderon called W1 for copy of admission agreement and monies paid to facility. Calls made on 3/22. 3/29, 4/11 and 5/25/2023, no response from W1.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20230207101222

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 1	FACILITY NUMBER: 198320196
	VISIT DATE: 02/15/2023

NARRATIVE

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Regarding Allegation #2: Facility staff illegally evicted resident from the facility.

This complaint alleged facility illegally evicted resident from the facility. LPA Calderon conducted an interview with A1. A1 expressed that no staff were offered a discount for using any specific hospice company. A1 expressed that R1 did not advised that if R1 did not use the facility hospice company that R1 family would have to return any money. A1 said that no staff told R1 family to move or gave written notice of eviction. A1 expressed that R1 moved out of the facility for unknown reason and no 30 day of eviction notice was given to R1 family after R1 moved. LPA Calderon conducted an interview with S1 who expressed that R1 family was happy with services provided by staff and hospice staff. S1 expressed that at no time did any staff offer any discount for rent if R1 family used hospice company that they work with. S1 expressed that at no time did any staff tell or suggest that R1 family would have to pay more money for services for changing hospice companies. S1 expressed that no 30 day or 60-day eviction notice was given to R1 family. S1 expressed that the R1 family moved R1 out of the facility (01/10/2022) with no additional monies owed. LPA Calderon conducted an interview with S3. S3 expressed that S3 was surprised that R1 family moved R1 out of the facility as S3 expressed that R1 family told S3 that R1 family was very happy with the care given to R1 by facility staff. S3 expressed to have no knowledge of any discounts offered/suggested or given to R1 family for rent. On 02/15/2023 LPA Calderon attempted to interview R2-R4. 4 out of 4 residents could not answer questions due to health conditions. On 02/15/2023 LPA Calderon reviewed facility paperwork for R1. Admission agreement (dated 12/06/2022) did not note any discount for using any specific hospice company and does not suggest any penalties for not using any specific hospice company. LPA Calderon noted no eviction notice was found or provided by R1 family for lack of payment or late payment. On 02/15/2023 LPA Calderon did not receive any notice from R1 family to suggest any eviction notice was given or suggested to R1 family for additional payment for services. LPA Calderon requested copy of eviction notice, proof of payment to facility from W1 on 3/22, 3/39, 4/11 and 5/25/2023 with no response.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “facility staff did not allow resident to choose health care provider” “facility staff illegally evicted resident from the facility” is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Natalya Trakhtenberg (A1).

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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