197608986-6-21-2023-29-AS-DPEA-CT8PL3-20230628112403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:54:35 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
04/11/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230411112334

FACILITY NAME:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR:	SARKIS DOVLATYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 6	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Sarkis Dovlatyan - Administrator		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Facility staff falsified records

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)s Brian Balisi and Zabel Chochian conducted a subsequent complaint visit to investigate the allegation listed above. Upon arrival, LPAs met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after.

On 4/13/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9 a.m. - 3:30 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents, responsible parties, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. LPA Balisi attempted to obtain Sweet Touch Hospice records on 04/12/2023 and 06/20/2023 but, was not successful. Today, at approximately 9:45 a.m., LPAs conducted a tour of the physical plant, interviewed staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation.

It was reported that facility staff falsified records as it was alleged that hospice services were being provided to Resident 1 (R1) from 12/19/2022 to 03/18/2023.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230411112334

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: 06/21/2023

NARRATIVE

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Continued from 9099

Information gathered during the investigation reflected that R1 was admitted to the facility on 12/19/2022, however the family responsible for R1 denies admitting R1 into hospice services. The family member also stated that neither facility staff nor any health care professionals ever discussed with the family about admitting R1 into any hospice services. Per hospital records and interview with the family, on 02/06/2023, R1 eloped from the facility and was later admitted into a local hospital (under investigation on Complaint Control #29-AS-20230131164509) and did not return to the facility. According to the family they obtained R1's belongings from the facility on 02/09/2023. Information obtained from records review and interviews conducted with responsible parties of other residents in care revealed that Resident 2 (R2) and Resident 3 (R3) were also receiving services from Sweet Touch Hospice. R3s responsible party stated R3s records indicated that R3 was receiving services from Sweet Touch Hospice from July 2021 to March 2023, but R3s responsible party also denied signing R3 up for any service with Sweet Touch Hospice. R2s responsible party stated they did in fact admit R2 into services with Sweet Touch Hospice. Interviews conducted with Administrator revealed that they have been business partners for approximately 10 years with Anna Hakobyan who has been identified as an individual associated with Sweet Touch Hospice. Administrator indicated they receive payments from all residents and denied any knowledge of any residents paying or being in contact with Anna. Administrator continued to state families may be in contact with Anna for hospice or home health services. Based on information obtained during the investigation, the department has sufficient evidence to determine that R1 received hospice services that they had not agreed to receive. Therefore, the above allegation is deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230411112334

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: 06/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2023 Section Cited CCR 87633(a)	1 2 3 4 5 6 7	The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill... in the facility when all the following conditions are met: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/30/2023.
	8 9 10 11 12 13 14	Based on information gathered during the investigation the licensee did not comply with the section cited as R1 and R3 were admitted into hospice services they did not agree to. This poses as a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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