Aging Eternity Retirement Home 1

Type of visit: Required - 1 Year

On 7/19/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Natalya Trakhtenberg and Serguei Kalistratov/Administrators. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above of which (6) may be bedridden. Facility has an approved hospice waiver for (3) patients. 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 Iniguez toured the physical plant with administrators. There were no bodies of water or obstructions on the premises. A total of (3) 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. 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 properly measured between 105°-120°F: Kitchen 104.9°F, Bathroom #1:105.7°F, Bathroom #2:104.3°F and Bathroom #3:104.7°F Evaluation Report Continues LIC 809-C LPA Iniguez 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 (3) residents' service files, (3) staff personnel files and (3) 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.the state’s words, verbatim · CDSS document, Jul 19, 2023

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

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 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. 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).the state’s words, verbatim · CDSS document, Feb 15, 2023 · control 11-AS-20230207101222

Type of visit: Prelicensing

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 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 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.the state’s words, verbatim · CDSS document, Jul 9, 2021