198320196-7-10-2024-11-AS-DESA-D72RBX-20240710125328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320196
Report Date: 07/10/2024
Date Signed: 07/10/2024 12:53:55 PM

Document Has Been Signed on 07/10/2024 12:53 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 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: 5	DATE:	07/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	Natalya Trakhtenberg Administrator		TIME COMPLETED:	01:15 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 07/10/24, Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA was met by Natalya Trakhtenberg Administrator and the purpose of today’s visit was explained. The facility is licensed to serve age range 60 and over, approved for (6) non-ambulatory, of which (6) may be bedridden and approved hospice waiver for 4. Facility has 8 rooms in total of which 6 are resident bedrooms, 6 bathrooms, a front den/sitting area, attached garage, dining room, living room, back shaded patio. 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. LPA toured the physical plant with administrators. There were no bodies of water or obstructions on the premises. A total of 8 rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. LIC 809C (cont)

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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 1	FACILITY NUMBER: 198320196
	VISIT DATE: 07/10/2024

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Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature measured between 105°-120°F. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of 5 residents' files, 5 staff personnel files and Medication Administration Records (MAR) were maintained in order. First AID kit was checked. LPA observed the facility's infection control practices.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Natalya Trakhtenberg.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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