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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320195
Report Date: 06/09/2021
Date Signed: 06/10/2021 09:50:35 AM

Document Has Been Signed on 06/10/2021 09:50 AM - It Cannot Be Edited

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 2FACILITY NUMBER:
198320195
ADMINISTRATOR:TRAKHTENBERG, NATALYAFACILITY TYPE:
740
ADDRESS:2581 MILITARY AVENUETELEPHONE:
(818) 519-3247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:TRAKHTENBERG, NATALYATIME COMPLETED:
04:30 PM
NARRATIVE
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A noncompliance meeting was conducted today for the above facility. In attendance was Regional Manager, Benita Yates, Licensing Program Manager, Angela Kendrick, Licensing Program Analyst, Troy Agard, and applicants Natalya Trakhtenberg and Serguei Kalistratov. During the meeting it was discussed that the applicants gained control of property in Oct 2020, operating the facility unlicensed and never notified licensing. Based on this information:

The following deficiencies under California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 809D.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/10/2021 09:50 AM - It Cannot Be Edited


Created By: Troy Agard On 06/10/2021 at 08:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AGING ETERNITY RETIREMENT HOME 2
FACILITY NUMBER: 198320195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2021
Section Cited
HSC
1503.5

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Unlicensed community care facility; definition; operation prohibited; procedure upon discovery (a) A facility shall be deemed to be an "unlicensed community care facility" and "maintained and operated to provide non-medical care" if it is unlicensed...
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Facility has a pending appilcation with CAB
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Based on interviews conducted and observation the operator is providing unlicensed care to residents. This poses an immediate Health and safety risk to residents in care.
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Type B
06/16/2021
Section Cited
HSC87405(d)(1)(2)(5)

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Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply Knowledge of the requirements for providing care and supervision appropriate to the residents..
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Applicant will review cited regulation and submit self certification to LPA stated they have reviewed and understand the regulation. Due by POC date
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Knowledge of and ability to conform to the applicable laws, rules and regulations. Good character and a continuing reputation of personal integrity. This requirement is not met as evidence by: Licensee/administrator failed to inform licensing of the change of ownership in Oct for 2020.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Angela J Kendrick
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021


LIC809 (FAS) - (06/04)
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