197608986-7-30-2024-29-AS-DPEA-D7PPEG-20240731111503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 07/30/2024
Date Signed: 07/30/2024 11:04:31 AM

Substantiated

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
07/14/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230714110246

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:	07/30/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sarkis Dovlatyan - Licensee		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility staff did not follow reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met wit Staff Zhyparkul Mursamambetova and explained the reason for the visit. Licensee Sarkis Dovlatyan arrived shortly after.

On 7/18/2023, the initial complaint visit was conducted by LPA Balisi between approximately 10:30 a.m. - 4:15 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents, responsible parties, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 11/21/2023, LPA reviewed North Los Angeles Regional Center Records for Resident #1 (R1). On 07/23/2024. LPA interviewed Juliet Allahverdi North Los Angeles Regional Center Service Coordinator
(NLARC)

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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-20230714110246

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: 07/30/2024

NARRATIVE

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Continued from 9099

It was reported that staff did not communicate promptly and appropriately with resident’s family / representative, as it was alleged that Resident #1 (R1) was admitted into the hospital , but facility staff did not inform R1. Interviews conducted and records review revealed that R1 resided at this facility from 05/16/2023 to 05/28/2023, when R1 was admitted into a local hospital. On 06/08/2023, R1’s family / representative requested to speak to R1 , but was told by Staff #1 (S1) that R1 was no longer at the facility and they were admitted into a local hospital. During the time of the investigation, S1 and staff at the facility did not have any knowledge of R1’s whereabouts after they were transported to the hospital. On 07/17/2023, (NLARC) located R1 at a Skilled Nursing Facility (SNF) in Downey, CA. On 07/18/2023, R1’s family / representative was notified of R1’s location. Based on information obtained during the investigation, the department has sufficient evidence to determine that R1’s family / representative was not contacted after being admitted into the hospital. Therefore, the above allegation “Staff did not communicate promptly and appropriately with resident’s family is deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-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. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230714110246

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/09/2024 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211(a)(1) Reporting Requirements - (1) A written report shall be submitted to the licensing agency and to the person responsible... if any; and disposition of the case. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit a statement of understanding demonstrating full understanding of the regulation cited and sent to LPA via email by COB 08/09/2024.
	8 9 10 11 12 13 14	Based on information gathered during the investigation the licensee did not comply with the section cited as R1’s Family / representative were not notified promptly when they were admitted into the hospital. This poses as a potential health and safety risks 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
	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) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

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