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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 05/18/2021
Date Signed: 05/18/2021 01:50:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AGE WELL ASSISTED LIVING FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 0DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Marine Sargsyan - Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Required Annual inspection. LPA met with Administrator Marine Sargsyan and explained the reason for the visit.

Between 1pm - 2pm, LPA conducted physical plant with Marine. There were no residents at the time of the visit, but Marine informed LPA they are actively searching for new clients. LPA did not observe any immediate health and safety concerns at this time.

Marine informed LPA that not all staff have been fit tested for N95 respirators.

LPAs advised Marine that they will provide resources to have all staff fit tested for N95 respirators.

Exit interview conducted with Marine , report issued and sent via E-mail.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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