197608986-6-29-2023-29-AS-DPEA-CTDUMF-20230703154215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 06/29/2023
Date Signed: 06/29/2023 07:16:25 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 Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230202134526

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:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	05:45 PM
MET WITH:	Sarkis Dovlatyan & Elena Kordonskiy		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility
Facility did not report resident missing in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver findings for the above allegations. Upon arrival LPA met with staff. Staff contacted Licensee Sarkis Dovlatyan who arrived shortly after LPA. Reason for visit was explained. Shortly after, staff Elena Kordonskiy arrived to the facility. Following complaint investigation was reviewed with Mr. Dovlatyan and staff E. Kordonskiy:
On 02/07/2023, the initial complaint visit was conducted by LPA Balisi between approximately 9:30 a.m. – 12 p.m. During the visit. LPA conducted a tour of the physical plant, interviewed staff, responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/21/2023, at approximately 9:45 a.m., LPAs Balisi and Chochian conducted physical plant tour, interviewed residents, and staff, as well as reviewed and obtained additional pertinent documents relevant to the investigation. During the course of the investigation, Calls for Service records were also obtained from Los Angeles Police Department (LAPD). On 06/21/2023 and 06/29/2023 additional interviews were conducted with the family of Resident #1 (R1). (continue to LIC9099c)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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-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: 06/29/2023

NARRATIVE

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It was alleged that lack of supervision resulted in R1 eloping from the facility and the facility failed to report R1’s elopement in a timely manner. Information gathered reflected that R1 has a diagnosis of Dementia and was admitted to the facility on 11/22/2022. R1 only resided at the facility for seven (7) days and was relocated to a different facility. Interviews conducted and records reviewed revealed that R1 eloped from the facility at approximately 7:00 a.m. on 11/25/2022. Interviews further reflected that the family of R1 was not contacted by facility staff and was unaware that R1 eloped from the facility until the family was notified by LAPD. Based on LAPD records, on 11/25/2022 at 10:48 a.m., law enforcement was notified of R1 missing from facility. It was notated that R1 was last seen one and half hours ago, suffers from Alzheimer’s, and was new to the facility. Law enforcement began a search for a missing person and at 12:11 p.m., additional units were requested for “Critical Missing” person. An “Official Adult Teletype” was created at 2:24 p.m. for a missing person with the public to contact LAPD with any information. R1 was located on 11/28/2022 at 3:54 p.m. and was transported to the hospital. Moreover, the family of R1 was informed that additional staffing will be hired as an extra safety precaution however, R1 subsequently eloped twice after. Interviews conducted with staff reflected that staff were not able to recall R1 nor, any elopements related to R1. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision R1 eloped from the facility and that facility failed to report R1’s elopement in a timely manner; therefore, the above allegations are deemed SUBSTANTAITED at this time.

Pursuant to Title 22 the following citations were issued. (Refer to LIC9099-D)

Exit interview was conducted. Citations issued/ A copy of report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 06/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/30/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee stated that he has terminated staff since the multiple elopement incidents at the facility. Furthermore, Licensee agrees to review with staff current residents care plan and ensure proper supervision is provided for residents. Submit self certification letter for the above by 06/30/2023.
	8 9 10 11 12 13 14	Based on interviews and records reviewed Licensee did not ensure supervision was provide to R1; as result R1 eloped from facility.	8 9 10 11 12 13 14	In addition, Licensee shall provide an updated LIC500 - Personnel Schedule showing sufficient staff coverage based on residents care needs. Also submit copy of in-service training provided to staff. Submit by 6/30/2023
Type B 07/03/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8)To have their representatives regularly informed by the licensee of activities related to care..... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to review section cited and provide how they will ensure this requirement is followed. Provide a self certification letter to the department by 07/03/2023.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, Licensee did not report R1 missing in a timely manner.	8 9 10 11 12 13 14

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: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

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