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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 12:50:13 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
11/08/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231108131542
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:
12:30 PM
ALLEGATION(S):
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Facility staff were unable to provide resident medical information to emergency responders.

Facility staff are unable to communicate due to language barrier.
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 11/16/2023, the initial complaint visit was conducted by LPA between approximately 11:30 a.m. - 12:30 p.m. During the visit, LPA’s conducted 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 staff were unable to provide resident medical information to emergency responders" and "Facility staff are unable to communicate due to language barrier", as it was alleged that Staff were unable to communicate with responders regarding resident medical history or status of resident.
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 5
Control Number 29-AS-20231108131542
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

Interviews conducted with Staff #1 (S1) revealed they recall when emergency responders were attempting to obtain information regarding Resident #1 (R1), however S1 stated they were not able to effectively communicate with them via a translation app on their phone and they were unable to get a hold of Licensee Sarkis Dovlatyan and Administrator Assistant Elena Kordonskiy during their visit. Based on information obtained during the investigation, the department has sufficient evidence to determine these allegations occurred. Therefore, the above allegations “Facility staff were unable to provide resident medical information to emergency responders" and "Facility staff are unable to communicate due to language barrier" are deemed SUBSTANTIATED at this time.

A Repeat Violation Civil Penalty is assessed in the amount $250.00 for deficiency that was previously cited on 12/30/2024 on Complaint Control # 29-AS-20231006113147. Licensee 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 deficiencies are cited (refer to LIC 9099-D).

During the visit Sarkis Dovlatyan had to leave the facility due to personal reasons, but stated staff can sign in their place.

Exit interview conducted, appeal rights discussed, and a 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: 2 of 5
Control Number 29-AS-20231108131542
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
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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Licensee agreed to provide updated LIC 500, review section cited and ensure to have staff scheduled that can communicate with residents in care and outside agencies. Licensee also agreed to submit statement of understanding via email to CCL by EOD 12/31/2024
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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 effectively, which posed an immediate personal rights and 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: 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: 3 of 5
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
11/08/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231108131542

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:
12:30 PM
ALLEGATION(S):
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9
Resident medication was expired and not up to date
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 11/16/2023, the initial complaint visit was conducted by LPA between approximately 11:30 a.m. - 12:30 p.m. During the visit, LPA’s conducted 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 "Resident medication was expired and not up to date" as it was alleged that medication was observed to be not up to date and possibly expired”. Interviews conducted and records review revealed S3 recalls providing R1 with medication as prescribed.
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: 4 of 5
Control Number 29-AS-20231108131542
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-A

Interviews conducted reflected the current residents have no concerns related to medication management. LPA’s medication audit for residents in care at the time of the complaint revealed that medications were administered as prescribed at this time. However, during medication audit, LPA observed that the facility did not maintain a centrally stored medication log for R1. Therefore, the LPA was unable to ensure if medication was provided per physician's orders for R1 at this time. 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 “Resident medication was expired and not up to date", is deemed Unsubstantiated at this time.

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

During the visit Sarkis Dovlatyan had to leave the facility due to personal reasons, but stated staff can sign in their place.

Exit interview conducted, appeal rights discussed 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: 5 of 5