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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:40:24 AM


Document Has Been Signed on 03/18/2024 11:40 AM - 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 FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 6DATE:
03/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sarkis Dovlatyan - LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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On 03-18-2024, Licensing Program Analyst (LPA) Brian Balisi met with Sarkis Dovlatyan for an unannounced Case Management visit to issue a civil penalty per Health and Safety Code §1569.49(f).

On January 31, 2023, the Department received a complaint alleging facility staff lack of care and supervision resulted in a resident (R1) eloping from the facility multiple times.

On June 21, 2023, the allegation was substantiated, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, Section 87464(f)(1) Basic Services due to a lack of care and supervision which resulted in R1 eloping from the facility on multiple occasions and sustaining serious injuries. An immediate civil penalty of $500 was also assessed for a violation of CCR Title 22, Section 87464(f)(1) Basic Services. The licensee was also informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injury while under the care of this facility. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee’s failure to provide adequate care and supervision, resulting in R1 eloping from the facility last on February 6, 2023. The resident was struck by a motor vehicle and sustained multiple rib fractures and a hematoma to forehead.

Today, 03/18/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 03/18/2024
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Continued from 809

A copy of the LIC 421D was given to Sarkis Dovlatyan and originals were signed.

Exit interview conducted. A copy of the report was issued. Appeal Rights provided. Sarkis Dovlatyan signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/18/2024 11:40 AM - 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: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
HSC
1569.317

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1569.317 Absentee notification plan for missing residents. Every residential care facility... missing from the facility...shall notify local law enforcement when a resident is missing from the facility. This requirement is not met as evidenced by:
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Licensee agreed to review regulation cited and submit statement of understanding to LPA via email by 03/29/2024 EOD.
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Based on (interview/record review) the licensee did not comply with the section by not implementing an absentee notification plan for missing resident, which is a potential health, and safety concerns 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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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