Community Care Licensing

Document Has Been Signed on 09/04/2025 04:52 PM - It Cannot Be Edited

FACILITY NAME:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR/ DIRECTOR:	LALA SOGHOMONYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 4	DATE:	09/04/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Lala Soghomonyan		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera NAME OF LICENSING PROGRAM ANALYST: Brian Balisi LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 09/04/2025

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as a full bottle of bleach and gardening tools were observed accessible in the backyard, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	During the visit, staff relocated items to a secure location. Administrator agreed to review section cited and provide a written plan on how they will ensure future compliance and send to LPA via email by COB 09/05/2025.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type A

Section Cited

CCR

87411(a)

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interviews and records review, the licensee did not comply with the section cited above there was only (1) staff on schedule for multiple days, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review section cited, provide a written plan on how they will ensure future compliance along with an updated LIC 500 and send to LPA via email by COB 09/05/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type A

Section Cited

CCR

87405(d)

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and records review the licensee did not comply with the section cited above as the Administrator did not demonstrarte sufficient knowledge, availibility and qualifications as an Administrator, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure that an Administrator is present at the facility and has a clear understanding of regulations then send to LPA via email by COB 09/05/2025.

Type A

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as LPA's did not observe any trainings for staff on file, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future complaince. Administrator also agreed to conduct training with current staff and provide LPA with date the training wil be conducted by COB 09/05/2025. The Licensee also agrees to submit the requested documents,

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review , the licensee did not comply with the section cited above as R1 did not recieve medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Type A

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as centrally stored medication lists were not onsite to review which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as Insulin was observed in the fridge accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87208(a)

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as a plan of operation was not onsite to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with an updated plan of operation to LPA via email by COB 09/12/2025.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87706(a)(1)(C)

(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information: (C) Staff training describing the required training for direct care staff who provide dementia special care. At a minimum, the description shall include information on training to be provided, as specified in Health and Safety Code sections 1569.625 and 1569.626. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as there was no staff training onsite to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as LPA's did not observe a limited liability insurance onsite to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to provide Limited Liability insurance as well as review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Type B

Section Cited

CCR

87307(a)(2)(B)

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews the licensee did not comply with the section cited above as upon arrival into facility, S1 stated they were sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as no staff had valid First Aid / CPR training on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to have S1 obtain a valid first aid / cpr certificate. Administrator also agreed to review reg cited then submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87413(a)(1)

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and records review, the licensee did not comply with the section cited above as S1 has been working for multiple days without a day off, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87412(g)

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review , the licensee did not comply with the section cited above as there were no complete Direct care staff files onsite for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above as S1 did not have any training on file to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observationthe licensee did not comply with the section cited above as the facility did not have PUB 475 posted in the approripate size which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to obtain correct size and post it on the wall and will send LPA proof via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87219(a)

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews the licensee did not comply with the section cited above as staff have not encouraged residents to participate in activites which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87555(a)

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not comply with the section cited above LPA's did not observe a sufficient amount of food stored in fridge or pantry which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87555(b)(21)

(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above as a thermometer was not observed in the fridge or freezer, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a thermometer for fridge and freezer and provide proof to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87465(a)(8)

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as a complete first aid kit was not observed onsite which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a new first aid kit and review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87465(c)(3)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review , the licensee did not comply with the section cited above as there was no documentation on site to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above as all (4) residents in care did not have a complete facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review , the licensee did not comply with the section cited above as there as LPA's did not observe any emergency disaster drills to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to conduct an emergency disaster drill by the end of the month and provide documenation to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87609(b)(4)(A)

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). (A) The written agreement shall reflect the services, frequency and duration of care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review , the licensee did not comply with the section cited above as all (4) residents were either on Home health / or hospice, but there were no records availible to review, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87628(a)

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as S1 was observed administering Insulin to R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87632(d)(2)

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review , the licensee did not comply with the section cited above as no hospice notifications were provided to the Regional Office for (3) out of the (4) residents in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed send notification of hospice services for each resident on hospice. Administrator also agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025

Link to Parent Document Below:

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

Type B

Section Cited

CCR

87633(h)

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above LPA's did not observe a hospice file for (3) residents in care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to provide hospice files to LPA. Administrator also agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/12/2025.

Type B

Section Cited

CCR

87705(b)(1)

(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above as LPA's did not observe any training documents for staff , which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 09/05/2025.

Desaree Perera NAME OF LICENSING PROGRAM MANAGER: Brian Balisi NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025