197608986-7-18-2023-29-AS-BBAI-CTUV5H-20230718160757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:08:10 PM

Document Has Been Signed on 07/18/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 4	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Assistant Administrator Elena Kordonsky		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility. Upon arrival LPA met with head caregiver Zhyparkul Mursamambetova and explained the reason for the visit. Assistant Administrator Elena Kordonsky arrived shortly after. A tour of the physical plant was conducted with administrator approximately between 10:30am - 12:00pm LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: A tour of the physical plant was conducted. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bathroom is designated for staff use only. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. At approximately 11:15am the LPA observed non-perishable items in poor condition – Carrots (expired 07/09/2023), Pasta Sauce (expired 01/04/2023). Sharp objects are stored in a locked drawer to the right of the dishwasher. Medication is stored in a locked cabinet above the dishwasher. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/18/2023

NARRATIVE

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Continued from 809
Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom Residents have sufficient amounts of supplies for personal hygiene stored in the designated staff bathroom. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit. Laundry area was located in the staff bathroom as well. Cleaning supplies were observed stored in locked cabinets located in staff bathroom inaccessible to residents in care at this time.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. There was an Adult Dwelling unit located in the rear of the facility. LPA observed unit to be empty at this time and inaccessible to residents care. LPA observed storage unit to the left of the home. Storage unit was observed to store extra furniture, hardware and other items for facility use. The property is gated with a motorized gate leading into driveway.There is an entry way gate for client use and is single latched. No bodies of water noted at this time.

Medications: Medications review began at 11:50am The medications are centrally stored in a locked cabinet above the microwave. LPA reviewed medications for the (4) residents in care. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Records: LPA began reviewing Personnel and Resident Records at 01:20pm. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/18/2023

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Continued from 809-C

Two (2) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At 1:40pm, LPA observed that Staff 1 (S1) did not have a CPR First Aid Card on file and Licensee / Care Provider Sarkis Dovlatyan CPR First Aid card was expired. Personnel files for Administrator Khatchik Danielian and Assistant Administrator Elena Kordonsky were not observed on site at this time.
LPA interviewed Staff at approximately 3pm. LPA attempted to interview residents at 3:15pm, but (3) residents were sleeping and (1) declined to interview.

During today’s visit, the LPAs obtained copies of the following: staff roster, staff schedule, and resident roster.

The following deficiencies were observed (See LIC 809-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, appeal rights discussed and copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as two (2) out of two (2) files reviewed did not have a valid first aid / CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	LIcensee agreed to have all staff files to be complaint with first aid and CPR notification and will submit proof of certification via email to CCL by COB 07/28/2023.

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as there were no Administrator Files to review on site, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Licensee agreed to maintain valid Administrator files on site. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 07/28/2023.

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: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as two (2) out of the ten (10) canned goods inspected were observed to be pass their expiration dates, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Licensee discarded items at time of visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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