197608986-7-30-2024-29-AS-DPEA-D7PPKB-20240731112253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 07/30/2024
Date Signed: 07/30/2024 11:05:43 AM

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
09/15/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230915101714

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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Staff did not meet resident's medical needs.

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 9/18/2023, the initial complaint visit was conducted by LPA Balisi between approximately 01:30 p.m. - 4:30 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that “Staff did not meet resident's medical needs”, as it was alleged that Resident #1 (R1) requested to see a doctor due to feeling ill. Interviews and records review reflected that on 09/09/2023, R1 requested assistance from Staff #1(S1) due to feeling lightheaded.

Continued on 9099-C

Unsubstantiated

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-20230915101714

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

S1 informed R1’s Administrator who advised S1 to provide extra fluids and have R1 rest in bed. Additionally R1 stated they have not requested any assistance from S1 or other staff to contact their primary care physician. Furthermore R1 did not express any immediate or potential concerns for not being able to contact their primary care physician at this time. Interviews conducted with four (4) other residents in care revealed that all (4) residents did not express any immediate or potential concerns with staff assisting them with contacting their primary care provider. 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 did not meet resident's medical needs”, is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

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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