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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 12/30/2024
Date Signed: 12/30/2024 11:26:37 AM

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
10/06/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231006113147
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: 4DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sarkis Dovlatyan - LicenseeTIME COMPLETED:
11:30 PM
ALLEGATION(S):
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Staff is unable to effectively communicate with a resident in care

Facility staff did not ensure that resident received prescribed medications

Staff is not meeting the resident's hygiene need

Facility retained a resident that requires a higher level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Staff and explained the reason for the visit. Licensee Sarkis Dovlatyan arrived shortly after.

On 10/12/2023, the initial complaint visit was conducted by LPA between approximately 03:55 p.m. - 04:50 p.m. During the visit, LPA conducted a tour of the physical plant, medication audit, interviewed staff, residents, well as, reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Staff is unable to effectively communicate with a resident in care" as it was alleged that staff at the facility are unable to sufficiently communicate in English with residents in care. Interviews conducted with four (4) residents in care at the time of the complaint revealed that they all stated they could only communicate clearly with S1 through use of a translating app on their phone.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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 7
Control Number 29-AS-20231006113147
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: 12/30/2024
NARRATIVE
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Continued from 9099

The residents did not express any immediate concerns for their health and safety as staff are able to provide basic services, but each did express potential concerns that if there was an emergency that they would not be able to communicate with the emergency personnel. LPAs interview with S1 at the time of the complaint revealed that S1 was able to communicate with LPA without the use of a translating app, but it was limited. S1 stated they would be more comfortable to communicate with LPA with the use of a translating app. While using translating app, S1 was able to communicate regarding facility business and resident care needs however they stated they would contact Elena Kordonskiy in the event of an emergency. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Staff is unable to effectively communicate with a resident in care” has been Substantiated at this time.

It was reported that "Facility staff did not ensure that resident received prescribed medications", as it was alleged that R1 had not received any medication since being admitted into facility. Interviews conducted with S1 revealed they do not recall R1 coming into the facility with any medication at this time. R1 was at the facility for approx. ten (10) days and medication was never provided to S1 to administer to R1. R1 did not have a complete resident file at the facility. Therefore, LPA was unable to ensure medication was provided to R1 per physician's orders. Interviews and records did not reflect that the facility administrator nor staff attempted to contact the hospital R1 was discharged from nor R1’s Primary Care Physician (PCP) therefore, R1 did not receive their prescribed medication while residing at the facility. Based on the information gathered during the investigation, the department has sufficient evidence to determine R1 was not given medication as prescribed. Therefore, the above allegation is deemed Substantiated at this time.

It was reported that "Staff is not meeting the resident's hygiene needs" as it was alleged that R1 does not have a toothbrush and toenails were long. Interview conducted with S1, and Assistant Administrator Elena Kordonsky revealed that S1 and Elena have observed R1 brush their own teeth multiple times. In addition, S1 stated they did cut R1's fingernails, however, a podiatrist would have to make a visit to cut R1's toenails. S1 and Elena did not recall how long R1's toenails were at this time. Facility staff had no documentation to support if arrangements were made for a podiatrist to visit R1.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20231006113147
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: 12/30/2024
NARRATIVE
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Continued from 9099-C

Interviews with facility residents also reflected that S1 assists with cutting fingernails but no assistance has been provided regarding setting up regular podiatrist visits. Based on the information gathered, the Department has sufficient evidence to determine that staff did not meet R1’s hygiene/grooming needs. Therefore, the above allegation is deemed substantiated at this time.

It was reported that "Facility retained a resident that requires a higher level of care" as it was alleged that facility staff could not properly care for R1. Information gathered during the course of the investigation reflected that the facility did not have any of the required paperwork for R1 including but not limited to the Pre-Admission Appraisal, Needs and Services, and Physicians Report. Therefore, the facility staff were not knowledgeable to provide the services R1 needed upon discharge from the hospital and unable to provide LPA with specific services R1 required. Based on the information obtained, the Department has sufficient evidence to determine that the facility retained a resident that required a higher level of care. 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20231006113147
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions.
This requirement has not been met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding as well as a plan to ensure how they ensure that residents will be provided medications as prescribed and send to LPA via email by COB 12/31/2024
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 has not received (3) of their prescribed medications, which poses an immediate health and safety risk to residents in care.
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Type A
12/31/2024
Section Cited
CCR
87464(d)
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A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident... directly or through outside resources.

This requirement is not met as evidenced by:
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Licensee agreed to review section cited and provided statement of understanding along with a plan on how they’ll ensure to maintain full facility files and provide proper care to residents. Licensee will provide statement and plan to LPA via email by COB 12/31/2024
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Based on interviews and records review, the licensee did not comply with the above cited section, as staff accepted and retained R1 and did not have any required paperwork on file for R1 which posed a potential health, safety and personal rights 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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20231006113147
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87468.2(a)(1)
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To have a reasonable level of personal privacy in accommodations... communications, telephone, conversations... meetings of resident and family groups. This requirement was not met as evidence by
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POC cleared during the visit. Interviews with S1 revealed they are able to effectively communicate without use of translation app. LIC 500 indicates schedule is sufficiently staff with employees who can effectively communicate at this time.
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Based on interviews and observations, the licensee did not ensure there was staff scheduled who can communicate with residents in a language they can fluently communicate in, which posed a potential personal rights and health and safety risk to residents in care.
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Type B
01/10/2025
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident... and assistance...Section 87608, Postural Supports.

This requirement is not met as evidenced by:
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Licensee agreed to provide vendorized training to all staff on this section. Training will be planned by POC due date; Licensee will submit to CCL the plan to include trainer information and date. Proof of training, including sign in roster will be sent to CCL via email by COB date
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Based on interviews and records review, the licensee did not comply with the above cited section, as staff did not make any arrangements to have R1’s toenails were appropriately groomed, which posed a potential health, safety and personal rights 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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
10/06/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231006113147

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: 4DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sarkis Dovlatyan - LicenseeTIME COMPLETED:
11:30 PM
ALLEGATION(S):
1
2
3
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9
Facility did not prevent resident from developing pressure injuries while in care

Facility staff is not feeding a resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. During today’s visit, LPA met with Staff and explained the reason for the visit. Licensee Sarkis Dovlatyan arrived shortly after.

On 10/12/2023, the initial complaint visit was conducted by LPA between approximately 03:55 p.m. - 04:50 p.m. During the visit, LPA conducted a tour of the physical plant, medication audit, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Facility did not prevent resident from developing pressure injuries while in care" as it was alleged that Resident #1 (R1) had sustained three (3) stage 1 pressure injuries located on R1's ankles and knees
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20231006113147
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: 12/30/2024
NARRATIVE
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Interviews conducted with Staff #1 (S1) revealed they recall R1 only residing at the facility for approx. 10 days. During that time R1 was able to walk around facility and S1 does not recall R1 having any pressure injuries on their ankles or knees. LPA's interview with Resident #2 (R2) who shared a room with R1 recalled R1 being able to ambulate around the facility with some assistance from S1. R2 does not recall if they ever observed any bruising on R1's body or how long R1 resided at this facility at this time. LPA attempted to obtain additional information from the Reporting Party (RP) regarding the pressure injuries, however, was not successful. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Facility did not prevent resident from developing pressure injuries while in care", is deemed Unsubstantiated at this time.

It was reported that "Facility staff is not feeding a resident in care" as it was alleged that staff are not feeding R1 as it appeared that R1 has lost weight, and the RP was informed by Staff #1 (S1) that R1 does not eat. Interviews conducted with four (4) residents in care at the time of the complaint revealed that all (4) did not express any potential or immediate concerns of not being provided food in a timely manner. LPA's interview with S1 revealed that they do not recall informing R1's family that R1 refuses to eat, however they do recall that R1 would only want to eat at lunch and dinner. In addition, LPA's interview with Resident #2 (R2) who shared a room with R1 revealed they do not recall R1 not being fed in a timely manner at this time. During the physical plant tours, LPA observed a sufficient supply of perishable and non-perishable food properly stored. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Facility staff is not feeding a resident in care", is deemed Unsubstantiated at this time.

Licensee was cited on a separate Case Management for violations observed during the investigation.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7