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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:52:00 PM


Document Has Been Signed on 09/27/2024 12:52 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:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff - Zhyparkul MursamambetovaTIME COMPLETED:
01:00 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). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Staff Zhyparkul Mursamambetova and explained the reason for the visit. LPA contacted Licensee Sarkis Dovlatyan who stated they are unable to make the visit, but stated staff can sign in their place.

The facility did not submit a Special Incident Report (SIR) or death report to Community Care Licensing (CCL) to notify that Resident #1 (R1) was admitted to the hospital on 04/13/2024, and R1’s death in the hospital on 05/09/2024.

Facility admitted and retained R1 with unstageable pressure injuries to both heels and a Stage 2 pressure injury to sacro coccyx without submitting and exception request for the prohibited condition (unstageable pressure injuries) and obtaining approval from CCL.

Staff #1 (S1) stated they are the only staff at the facility and has worked as a caregiver at the facility since 03/15/2023. S1 stated they work “six days a week, 24 hours a day.” S1’s duties as a caregiver include cooking, cleaning, laundry, showering, changing diapers, and changing clothes. Resident #2 (R2) stated S1 works “24/7”.

Records review lists Lala Soghomonyan as Administrator, but there were no records to review on site. LPA contacted Lala who stated they were unable to make it to the facility.

Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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 3


Document Has Been Signed on 09/27/2024 12:52 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2024
Section Cited
CCR
87615((a)(1)

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(a) Persons who require health services for or have a health condition... admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by:
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The licensee agreed to review regulation cited and submit a memo of understanding that licensee will not admit or retain residents with prohibited health conditions without first submitting an exception request and receiving approval from CCL. Submit proof to CCL by COB 09/30/2024
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Based on records review, the licensee did not comply with the section cited above. which posed an immediate health and safety risk to residents in care.
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Type A
09/30/2024
Section Cited
CCR87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by
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The licensee agreed to submit a current and complete LIC500 Personnel Report reflecting adequate staff coverage 24/7 and include the administrator’s days and hours present at the facility. Submit proof to CCL by COB 09/30/2024.
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Based on interviews, the licensee did not comply with the section cited above. There was only one caregiver working at the facility, which posed an immediate 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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/27/2024 12:52 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87211(a)(1)(A)(B)

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Each licensee shall furnish to the licensing agency such reports... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The licensee agreed to submit a plan describing how they will ensure reporting requirements are followed and have administrator complete training in Reporting Requirement training. Submit proof to CCL by COB 10/04/2024.
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Based on records review, the licensee did not comply with the section cited above as Licensee did not submit an incident report on 04/13/2024 for R1's hospitalization, nor a death report on 05/09/2024 for R1, which posed a potential health and safety risk to residents in care.
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Type B
10/04/2024
Section Cited
CCR87412(d)

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(d) The licensee shall maintain documentation that an administrator... has met the certification requirements specified in Section87406....Administrator Recertification Requirements. This requirement is not met as evidenced by:
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LIcensee agreed to submit the required documents to CCL via email by COB 10/04/2024.
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Based on record review the licensee did not comply with the section cited above as the Administrator file is missing the following documents: LIC 501, LIC 503, TB Test, LIC 9052, SOC 341a, which poses a potential health, safety or personal rights risk to persons 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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3