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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:12:32 PM


Document Has Been Signed on 04/17/2024 12:12 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 FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 5DATE:
04/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elena Kordonsky - Assistant AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Brian Balisi  conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240416124733). LPA met with Elena Kordonsky and explained the reason for the visit.   The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

During the complaint investigation, LPA conducted a Residents records review at approx 10:30am and revealed that the facility does not maintain accurate resident records.  Two (2) out of Five (5)  resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. 

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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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Document Has Been Signed on 04/17/2024 12:12 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: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
87506(b)(F)

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87506(b)(F) Each resident’s record shall contain at least the following information...(17) documents and information...(F)Section 87505, Documentation and support.

This requirement was not met as evidenced by:
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Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 04/26/2024.
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Based on records review two (2) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. This poses a potential 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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