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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:55:49 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
02/02/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20230202134526
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: 6DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sarkis Dovlatyan - AdministratorTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Facility did not issue a refund

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 LPA’s met with staff Zhyparkul Mursamambetova and explained the reason for the visit. Administrator Sarkis Dovlatyan arrived shortly after.

On 02/07/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9:30am - 12pm. During the visit. LPA conducted physical plant, interviewed staff, responsible parties as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. Today at approximately 9:45am, LPAs conducted physical plant, interviewed residents, and staff as well as reviewed and obtained additional pertinent documents relevant to the investigation.

It was reported that facility did not issue a refund as it was alleged that the responsible party for Resident 1 (R1) was due a refund since November 2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (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)
Page: 1 of 4
Control Number 29-AS-20230202134526
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
Interviews conducted and records review revealed that R1 was admitted into this facility in 11/22/2022, but relocated out of the facility (7) days later. Resident records for R1 were not available onsite for LPAs to review. The responsible party stated they were charged $2,300 for thirty (30) days , but R1 resided in the facility for only (7) days. Records review further revealed communication via text messages between the responsible party and facility staff, confirming a refund was owed and due to be sent to the responsible party. The responsible party stated no refund has been issued at this time. Based on information obtained during the investigation, the department has sufficient evidence to determine that R1's responsible party has not received a refund. Therefore, the above allegation that facility did not issue a refund 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (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: 4 of 4
Control Number 29-AS-20230202134526
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
HSC
1569.651(g)
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If the applicant decides not to enter the facility prior to the facility’s completion of a preadmission appraisal... entitled to a refund of 100 percent of the preadmission fee. This requirement was not met as evidenced by:
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Licensee agreed to provide proof of refund and submit a Statement of Understanding demonstrating full understanding of the regulation cited and send to LPA via email by EOD 06/30/2023.
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Based on information gathered during the investigation the licensee did not comply with the section cited as per R1’s responsible party they have not received a refund as of 06/21/2023. This poses as a potential health and 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (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)
Page: 2 of 4