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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 07/10/2025
Date Signed: 07/10/2025 02:30:36 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
07/09/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250709155231
FACILITY NAME:AGE WELL ASSISTED LIVING FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR:LALA SOGHOMONYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 5DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Tamara BorisovnaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff does not ensure an appropriately Skilled Professional administers Glucose Testing and Insulin to resident
Staff is not competent to meet the needs of residents
Due to staff negligence, resident missed medications resulting in high blood sugar
Staff did not do a proper assessment of resident
Staff did not properly safeguard the residents medications
Licensee retained resident who is bedridden in a room without bedridden fire clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with staff and explained the reason for the visit. Licensee Sarkis Dovlatyan and Assistant Administrator Iveta Darabedym were all contacted and each stated they were unable to be onsite for the visit due to unforseen circumstances. Administrator Lala Soghomonyan was out of town during the visit. Licensee and Assistant Admin stated staff Tamara Borisovna could sign in their place.

At approx 10:00a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentaiton relevant to the investigation.

It was reported that "Staff does not ensure an appropriately skilled professional administers Glucose Testing and insulin to resident" and "Due to staff negligence, resident missed medications resulting in high blood sugar" as it was alleged that Resident #1 (R1) has resided at this facility for approx twelve (12) days and has not been administered insulin or Glucose testing.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 6
Control Number 29-AS-20250709155231
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: 07/10/2025
NARRATIVE
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 Interviews with Staff and Assistant Administrator confirmed that the insulin was never obtained and Glucose testing was not conducted. R1's file was not on site for review. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff does not ensure an appropriately skilled professional administers Glucose Testing and insulin to resident" and "Due to staff negligence, resident missed medications resulting in high blood sugar" has been deemed Substantiated at this time.

It was reported that "Staff is not competent to meet the needs of residents" as it was alleged that staff are unable to communicate effectively with residents and outside agencies. LPA's interview with three (3) out of five (5) residents in care revealed they could communicate their basic needs to Staff #1 (S1), however they could communicate more effectively with use of a translation app. (1) resident declined to be interviewed and another resident was in the hospital. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff is not competent to meet the needs of residents" has been deemed Substantiated at this time.

It was reported that "Staff did not do a proper assessment of resident" as it was alleged that Licensee was unaware who conducted pre-appraisal assessment of R1. LPA's records review of resident records revealed two (2) out of five (5) residents in care did not have a pre-appraisal assessment completed in their file. Interview with Assistant Administrator revealed that an assessment was completed , but staff onsite could not locate R1's records for review.  Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not do a proper assessment of resident " has been deemed Substantiated at this time.

During the complaint visit ,It was observed that "Staff did not properly safeguard the resident's medications" ,during physical plant and interviews with residents, LPA observed multiple prescribed medication stored and easily accessible in the rooms of Resident #2 (R2) and Resident #3 (R3). Interviews with R2 and R3 revealed they prefer to store it with them. Residents were advised of Title 22 regulations regarding the storage of medications.  Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not properly safeguard the residents medications " has been deemed Substantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250709155231
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: 07/10/2025
NARRATIVE
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Continued from 9099-C

During complaint visit it was observed that "Licensee retained resident who is bedridden in a room without bedridden fire clearance" as LPA's records review revealed Resident #4 (R4) was admitted to the facility and is listed as bedridden. Records review of facility file revealed only Bedroom #3 is cleared for bedridden residents and R4 is located in bedroom #1, which has no direct exit to the outside. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Licensee retained resident who is bedridden in a room without bedridden fire clearance " has been 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/or California Health and Safety Code. An immediate $500 civil penalty issued today for fire clearance violation.

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: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20250709155231
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: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
CCR
87629(b)(1)
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Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding along with a written plan on how they will ensure future compliance then submit to LPA via email by COB 07/11/2025.
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Based on interviews and records review, the Licensee did not comply with the section cited above as R1 has not received glucose testing or insulin, which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
07/11/2025
Section Cited
CCR
87465(c)(2)
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 Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding along with a written plan on how they will ensure future compliance then submit to LPA via email by COB 07/11/2025.
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Based on interviews , the Licensee did not comply with the section cited above as R1 has not been receiving their insulin injections, which poses an immediate 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: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250709155231
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: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
CCR
87465(h)(2)
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(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement has not been met as evidenced by:
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Licensee instructed staff to relocate medication into centrally stored location. Licensee also agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email by COB 07/11/2025
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Based on observation and interviews the Licensee did not comply with the section cited above as R2 and R3 stored their prescribed medications in their room, which poses an immediate health, safety and personal rights risk to residents in care
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Type A
07/11/2025
Section Cited
CCR
87202(a)(2)
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(a)All facilities shall maintain a fire clearance... approved by the city, county, or city and county fire department, or...(2) Bedridden persons. This requirement was not met as evidence by:
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Licensee agreed to immediately relocate R4 to a room that has appropriate fire clearance and review section cited, submit a statement of understanding and proof of R4's relocation to LPA by COB 07/11/2025.
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Based on records review and interviews the Licensee did not comply with the section cited above as R4 is listed as bedridden and resided in a room that did not have fire clearance for bedridden residents which poses an immediate health and safety 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: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250709155231
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: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
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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Licensee agreed to provide an updated LIC 500, and agreed to 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 COB 07/18/2025
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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 poses a potential personal rights and health and safety risk to residents in care.
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Type B
07/18/2025
Section Cited
CCR
87457(c)
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Prior to admission a determination of the prospective resident's suitability... comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement was not met as evidence by:
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Licensee agreed to review section cited, keep full facility file and create a written plan on how they will ensure future compliance then send to LPA via email by COB 07/18/2025.
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Based on interviews and records review the licensee did not ensure a pre-appraisal was completed or onsite for (3) out of (5) residents in care which poses a potential 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: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6