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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:48:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240416124733
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: 5DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff Zhyparkul MursamambetovaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not transport resident to medical appointments.

Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. Upon arrival LPA met with Staff Zhyparkul Mursamambetova and explained the reason for the visit LPA contacted Licensee Sarkis Dovlatyan who stated they are unable to make the visit, but stated staff can sign in their place.

On 04/16/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/ lack of care. The complaint alleged that the staff neglected to transport Resident #1(R1) to medical appointments (dialysis). The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Christine Ferris.
On 04/17/2024, from 9:30 a.m. to 12:30 p.m., LPA Balisi conducted an initial 10-day complaint visit to investigate the allegation listed above. At approximately 10:00 a.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 09/27/2024
NARRATIVE
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Continued from 9099

On 05/28/2024, from approximately 12:30 pm to 2:45 p.m., Investigator Ferris conducted interviews with residents, caregiver, Resident #2’s (R2’s) resident representative, and Assistant Administrator; on 06/03/2024, at approximately 1:30 p.m., with R1’s resident representative; on 06/10/2024, from approximately 9:45 a.m. to 1:00 p.m., with Catered Manor Nursing Center Administrator, Social Worker, and Case Manager, with Vanalden Villa staff, and R1’s resident representatives: and on 06/17/2024, at approximately 1:00 p.m., with DaVita Warner Center Dialysis Center Administrative Assistant. In addition, the investigator reviewed Valley Presbyterian Hospital medical records, Catered Manor Nursing Center medical reports, and death certificate for R1. There was not a complete resident file for R1 available to review and the licensee was cited on a separate report during the initial complaint visit on 04/17/2024.

According to the information provided by the facility caregiver and assistant administrator, R1 was placed at the facility on 04/10/2024 and they were not provided with any documents or information concerning R1. They were aware R1 needed dialysis three times per week, but stated there were issues with the transportation company and R1 did not receive dialysis while in the facility. On 04/13/2024, R1 was taken to the hospital.

Interviews with the DaVita Warner Center Dialysis Center revealed the board & care facility did not arrange transportation and Warner Center Dialysis Center was not responsible for arranging the patient’s (R1’s) transportation to dialysis. In addition, information provided by the Catered Manor Nursing Center Social Worker revealed R1’s insurance authorization for transport was completed and the assisted living facility was responsible to make arrangements with the transport company for R1’s dialysis appointments.

The review of the Valley Presbyterian Hospital medical records revealed R1 was admitted to the Emergency Room (ER) on 04/13/2024 at 11:22am. The patient notes indicated R1 was brought in by ambulance for fever, weakness, and missed dialysis. R1’s medical history included alcohol abuse, end-stage renal disease on hemodialysis, and hypertension.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 09/27/2024
NARRATIVE
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Continued from 9099-C
R1 stated that R1 has hemodialysis three times a week but has not had dialysis for two weeks for unknown reasons. Chest x-ray showed possible pneumonia. Pulmonary/critical care, nephrology consulted for further recommendations and R1 was admitted to the intensive care unit for further care including careful hydration, antibiotic therapy, and infectious source control. R1 was diagnosed with Sepsis, unspecified organism, other toxic encephalopathy, pneumonia, unspecified organism, severe sepsis with septic shock, end stage renal disease, E coli bacteremia, source permacath (permanent catheter for dialysis, unstageable pressure injuries on left and right heel, and stage 2 pressure injury to sacro coccyx. On 05/09/2024, R1 passed away in the hospital. The death certificate listed the primary cause of death as alcoholic cirrhosis of the liver and end stage renal disease.

Based on the Department’s investigation, staff did not arrange for the dialysis transportation to ensure R1 got to the dialysis center (R1 was supposed to have dialysis 3 times per week), which led to R1 missing the dialysis treatments for the time R1 resided at the facility 04/10/2024 – 04/13/2024, which then led to the hospitalization on 04/13/2024 at 11:22 a.m. with the diagnosis of end stage renal disease, sepsis, UTI, unstageable pressure injuries and stage 2 pressure injury and admitted to intensive care for further care. Therefore, the allegation “Staff did not transport resident to medical appointments” is deemed Substantiated at this time.

It was reported that "Staff did not administer resident's medication as prescribed" as it was alleged that R1 was not administered medications as prescribed while residing at this facility. Interviews conducted and records review revealed R1 resided at this facility from 04/10/2024 to 04/13/2024 when R1 was admitted into the hospital. LPA's interview with Staff and Administrator revealed they did not administer any medication for R1 while they resided here. LPA's records review of R1's hospital records indicated R1 was prescribed the following medications: Norepinephrine 250ml@7.5mis/hr,Ondansetron HCI (Zofran lnj)4mg, Acetaminophen (Tylenol Tab) 650 mg,Sodium Chloride 1,000 ml @ 50 m ls/hr Q20H IV, IV Flush (NS 3 ml) 3 mlPER PROTOCOL IV; Ondansetron HCI (Zofran lnj) 4 mg Q6H PRN IV NAUSEA AND/OR VOMITING;Heparin Sodium (Porcine) (Heparin (5000 Units/1 ml)) 5,000 unit 012 SUBQ ,Adm in Dose 5,000 UNIT; Acetaminophen (Tylenol Tab) 650 mg Q6H PRN PO MILD PAIN; , Morphine Sulfate (morphine) 2 mg 04H PRN IV SEVERE PAIN; Naloxone HCI (Narcan) 0.4 mg Q2M PRN IV RR 8 BREATHS/MIN OR LESS; Vancomycin HCI (Vanco Iv Per Pharmacy) VANCOMYCIN PER PHARMACY PER PROTOCOL XX;
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2024
Section Cited
CCR
87465(a)(2)
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A plan for incidental medical and dental care shall be developed...In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement is not met as evidenced by
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Licensee agreed to submit a plan on how they will ensure residents receive transportation to medical/dental appointments. Submit to CCL via email by COB 09/30/2024
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Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not arrange for transportation to ensure R1 got to the dialysis treatment center, which posed an immediate health and safety risk to residents in care.
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Type A
09/30/2024
Section Cited
CCR
87465(a)(4)
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The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by
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Licensee agreed to review section cited and submit a statement of understanding and how they plan to ensure residents will receive their medications as prescribed and submit to CCL via email by COB 09/30/2024
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Based on interviews and records review, the licensee did not comply with the section cited above, as staff did not provide R1 medication to R1 while they resided at the facilty, which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240416124733

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: 5DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff Zhyparkul MursamambetovaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
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9
Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care resulting in resident sustaining pressure injuries, septic shock, and an E coli infection.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. Upon arrival LPA met with Staff Zhyparkul Mursamambetova and explained the reason for the visit LPA contacted Licensee Sarkis Dovlatyan and stated staff can sign in their place.

On 04/16/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/ lack of care and supervision. The complaint alleged that the staff neglected or failed to provide an adequate level of care resulting in Resident #1 (R1) sustaining pressure injuries, septic shock, and an E coli infection. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Christine Ferris.
On 04/17/2024, from 9:30 a.m. to 12:30 p.m., LPA Balisi conducted an unannounced initial 10-day complaint visit to investigate the allegation listed above. At approximately 10:00 a.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 09/27/2024
NARRATIVE
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Continued from 9099

On 05/28/2024, from approximately 12:30 p.m. to 2:45 p.m., Investigator Ferris conducted interviews with residents, caregiver, Resident #2’s (R2’s) resident representative, and Assistant Administrator; on 06/03/2024, at approximately 1:30 p.m., with R1’s resident representative; on 06/10/2024, from approximately 9:45 a.m. to 1:00 p.m., with Catered Manor Nursing Center Administrator, Social Worker, and Case Manager, with Vanalden Villa staff, and R1’s resident representatives: and on 06/17/2024, at approximately 1:00 p.m., with DaVita Warner Center Dialysis Center Administrative Assistant. In addition, the investigator reviewed Valley Presbyterian Hospital medical records, Catered Manor Nursing Center medical reports, and death certificate for R1. There was not a complete resident file for R1 available to review and the licensee was cited on a separate report during the initial complaint visit on 04/17/2024.

According to the information provided by the facility caregiver and assistant administrator, R1 was placed at the facility on 04/10/2024 and they were not provided with any documents or information concerning R1. They were aware R1 needed dialysis three times per week, but stated there were issues with the transportation company and R1 did not receive dialysis while in the facility. On 04/13/2024, R1 was taken to the hospital.

The review of the Valley Presbyterian Hospital medical records revealed R1 was admitted to the Emergency Room (ER) on 04/13/2024 at 11:22 a.m. The patient notes indicated R1 was brought in by ambulance for fever, weakness, and missed dialysis. R1’s medical history included alcohol abuse, end-stage renal disease on hemodialysis, and hypertension. R1 stated that R1 has hemodialysis three times a week but has not had dialysis for two weeks for unknown reasons. Chest x-ray showed possible pneumonia. Pulmonary/critical care, nephrology consulted for further recommendations and R1 was admitted to the intensive care unit for further care including careful hydration, antibiotic therapy, and infectious source control.

R1 was diagnosed with Sepsis, unspecified organism, other toxic encephalopathy, pneumonia, unspecified organism, severe sepsis with septic shock, end stage renal disease, E coli bacteremia, source permacath (permanent catheter for dialysis, unstageable pressure injuries on left and right heel, and stage 2 pressure injury to sacro coccyx. On 05/09/2024, R1 passed away in the hospital. The death certificate listed the primary cause of death as alcoholic cirrhosis of the liver and end stage renal disease.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 09/27/2024
NARRATIVE
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Continued from 9099-C

The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. R1 was discharged on 04/05/2024 from Catered Manor Nursing Center to Vanalden Villa with Stage 4 pressure ulcers of the right and left heels, and a sacro coccyx deep tissue injury. Per the Valley Presbyterian Hospital medical records, on 04/13/2024, R1 was diagnosed with sepsis with an unclear source and E coli bacteremia, source permacath (permanent catheter for dialysis), and septic shock, suspect secondary to E coli bacteremia with the source unclear, unstageable pressure injuries to right and left heel, and stage 2 pressure injury to sacro coccyx. Per the Age Well Assisted Living Facility Assistant Administrator and caregiver, R1 resided at Age Well Assisted Living facility from 04/10/2024 to 04/13/2024 when R1 was sent to the hospital. Per R1’s resident representative, R1 resided at Age Well Assisted Living Facility for about “three days” but they never visited R1. Based on the statements and documentation provided, the Department found insufficient evidence to determine if there was neglect or lack of care on behalf of the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation of “Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care resulting in resident sustaining pressure injuries, septic shock, and an E coli infection” is deemed to be Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20240416124733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 09/27/2024
NARRATIVE
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Continued from 9099-C

Cefepime HCI 2 gm/ Sodium Chloride 50 ml@ 100 mis/hr Q24H IVPB , Heparin Sodium (Porcine) (Heparin (1000 Units/ml)) 4,000 unit AFTER DIALYSIS CATHETER ; Albumin Human 100 ml@ 100 mis/hr ONCE PRN IV SBP LESS THAN 90 DURING HD; ,Sodium Chloride 1,000 ml@ 2,000 mis/hr Q30M PRN IV SBP LESS THAN 90 DURING HD; Sodium Chloride 250 ml@ 0 mis/hr QOM IV ; Sodium Chloride 250 ml@ 0 mis/hr QOM IV ; Alteplase, Recombinant (Cathflo (Activase)) 2 mg MAY REPEAT x1 PRN Norepinephrine 250 ml@ 1.875 mis/ hr ONCE STAT IV Albumin Human 100 ml@ 100 mis/hr Q8H IV. Start date for each medication was 04/13/2024. Based on information obtained during the investigation, the department has sufficient evidence to determine that Staff did not administer resident's medication as prescribed while residing at the facility.Therefore, the above allegation “Staff did not administer resident's medication as prescribed" is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The staff was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8