197608986-12-16-2021-29-AS-ZCHN-C9S2A2-20211216161248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:15:04 PM

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:	12/16/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Dinah Pasco - Assistant Administrator		TIME COMPLETED:	04:30 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) Zabel Chochian initiated a Case Management visit today. Upon arrival LPA rang the door bell a couple of times and no one answered. LPA called facility and spoke with staff Wynn Apao. Staff stated to LPA that they did not hear the door bell ring. LPA asked staff to test the door bell while LPA waited inside. Facility door bell ring could not be heard in the facility. Staff contacted Licensee and the electronic door bell system was reset and functioning upon reset of the system during LPA's visit.

Reason for visit as explained to Staff. Staff contacted back-up administrator Dinah Pasco. LPA as informed that facility administrator Sarkis D. is not available at this time. LPA explained reason for the visit.

On 12/05/21, this facility submitted a Death Report for resident #1 (R1) which noted a stage 3 pressure injury. Follow Information was gathered from Licensee/Administrator Sarkis D. and backup Administrator Dinah P.

R1 was discharged from Kaiser Permanente - Downey and admitted to this facility on 11/26/2021 with stage 3 pressure injury on buttocks area. According to Ms. Pasco R1 was admitted to the facility with stage 4 cancer and pressure injury. Ms. Pasco stated that she was not aware of the staging of the wound until after R1 was admitted. Ms. Pasco also stated that they were in the process of getting the resident on hospice. However, on 12/1/2021 she discussed with R1's family and decided to transfer resident back to the hospital for further evaluation of the wound. Resident 1 passed way on 12/3/2021 at Kaiser Permanente - Woodland Hills. Ms. Pasco stated that she is waiting for a death summary from Kaiser and will submit to case LPA soon as she receives the death summary.

During today's visit, a file review was conducted at 2:30 p.m. Physician report dated 10/21/2021, indicated R1 had a Stage 3 pressure injury. Ms. Pasco admit that its their fault for not obtaining record of the wound staging prior to admitting R1. Based on the investigation, there is sufficient evidence to support that R1 was admitted to and retained in this facility for several days with a prohibited health condition. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. A copy of the report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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 2

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: 12/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/17/2021 Section Cited	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition ... shall not be admitted or retained in a residential care facility for the elderly: Stage 3 or 4 pressure injuries. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interview and records review, the licensee did not comply with the section cited above, as they admitted and retained R1 in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2