197608986-5-7-2024-29-AS-DPEA-D5KQVC-20240524123008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:06:01 PM

Unsubstantiated

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
05/01/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240501152412

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: 5	DATE:	05/07/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Zhyparkul Mursamambetova, Staff		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Staff speak inappropriately to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a complaint visit to this facility regarding above allegation. Upon arrival LPA met with staff and reason for the visit was explained. Staff contacted Administrator Sarkis Dovlatyan and Administrator assistant Elena Kordonskiy. Mr. Dovlatyan stated that he is in a meeting and wont be available today. LPA spoke with Ms. Kordonskiy who stated that she is out of town and will be back tomorrow.

Following is a summary of the allegation and investigation conducted:

On May 1, 2024, the Department received a complaint alleging that staff speak inappropriately to resident. Concerns reported were that "a nurse" at the facility calls resident (R1) "profanity names" and "spits" in resident's face when they talk. It is unknown if the nurse intentionally spits in resident's face. According to the reporting party there is no additional information available regarding the allegation.
(Continue to LIC9099c).

Unsubstantiated

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: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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-20240501152412

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: 05/07/2024

NARRATIVE

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During todays visit LPA obtained copy of the facility resident roster and the personnel report. Between 12:30pm-2pm LPA conducted interviews with staff, five (5) residents and a potential witness. Additional potential witnesses were interviewed at approximately 2:30pm and 3:30pm. Staff and potential witnesses interviewed denied the allegation. During resident interviews, four (4) out of five (5) residents were able to comprehend questions asked and expressed that they are not mistreated by any staff or "nurse". Residents interviewed expressed that visiting nurses and staff are helpful and nice. Residents interviewed stated that they are not mistreated and have not observed any mistreatment in the facility by any staff or nurses. Potential witnesses interviewed stated that they have not observed any resident be mistreated by staff or any visiting nurse.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff speak inappropriately to resident” is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

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