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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 06/27/2025
Date Signed: 06/27/2025 02:59:17 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
10/14/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20241014112146
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:
06/27/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sarkis DovlatyanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not ensure residents repsonsible party received pro-rated refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings for the allegation listed above. Upon arrival LPA met with staff and explained the reason for the visit. Licensee Sarkis Dovlatyan arrived shortly after.

On 10/18/2024, the initial complaint visit was conducted by LPA between approximately 09:45 a.m. - 02:00 p.m. During the visit, LPA conducted a tour of the physical plant, medication audit, interviewed staff as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Staff did not ensure residents responsible party received pro-rated refund" as it was alleged that the family of Resident #1 (R1) had not received a refund check in the amount of $850 in a timely manner, after R1 no longer resided at the facility. Interviews conducted with Administrator revealed they stated they had already generated a refund check but they were not able to provide proof of check during the initial visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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 3
Control Number 29-AS-20241014112146
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: 06/27/2025
NARRATIVE
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Continued from 9099

LPAs interview with family member of R1 after the initial visit on 10/18/2024 revealed R1 had resided at the facility for approx (3) months. R1 was relocated out of the facility on 06/18/2024 and the family of R1 picked up R1's belongings on 06/20/2024. They were told they would receive a pro-rated refund check within a week. But as of 10/18/2024 they had yet to receive the check. On 10/25/2024, LPA interviewed family member of R1 who stated they had just received the check in the amount of $850 on 10/23/2024. Based on information obtained during the investigation, the department has sufficient evidence to determine this allegation occurred. Therefore, the above allegation “Staff did not ensure residents responsible party received pro-rated 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

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

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241014112146
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: 06/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2025
Section Cited
HSC
1569.652(c)
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Health&Safety§1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be...resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by
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On 10/25/2024, family of R1 confirmed to LPA they had received a check for the amount of $850 from the facility covering the refund due. Licensee also agreed to review section cited and submit a statement of understanding to ensure future compliance then send to LPA via email by COB 7/7/2025.
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Based on interview and record review, the Licensee did not comply with the section cited above, as a refund check was not provided to family of R1upon relocating from facility, which poses a potential 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: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3