197608986-11-18-2025-29-AS-ZCHN-DNJVGP-20251118152554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 11/18/2025
Date Signed: 11/18/2025 03:26:47 PM

Document Has Been Signed on 11/18/2025 03:26 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 FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR/ DIRECTOR:	NAILAH TATUM		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 2	DATE:	11/18/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Devid Davydov		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 conducted an unannounced case management visit - other to ensure the health and safety of the residents in care. Upon arrival LPA met with staff and explained the reason for the visit. Staff contacted Licensee representative, Sarkis Dovlatyan. During todays visit, LPA conducted a physical plant tour with staff at approximately 12:05 p.m.. LPA observed a sufficient supply of perishable and non-perishable food properly stored at the time of the visit. LPA observed fresh produce, eggs, sausages, deli meat, chicken and condiments in the fridge; frozen poultry, fish sticks, crab, frozen vegetables and other frozen goods observed in the freezer. LPA also observed dried and canned food items in the storage. Common areas, restroom and resident bedrooms observed clean and odor free. Residents were interviewed from approximately 12:15 and 12:30 p.m. Interviews with residents revealed they have been provided with sufficient meals and snacks since the last inspection visit on 11/12/2025 and residents did not express any concerns at this time. At approximately 12:45, Mr. Dolatyan called the facility and spoke with LPA. Reason for the visit was explained. Mr. Dovlatyan explained that he is unable to come to the facility and the Administrator Nailah Tatum is currently in class and wont be available until after 5 p.m. LPA contacted the Administrator and left a voicemail message.LPA spoke with Mr. Dovlatyan by telephone again at approximately 1:30 p.m. LPA asked Mr. Dovlatyan if he received the Accusation filed and dated on 11/13/2025. Mr. Dovlatyan stated that he received a great amount of documents few days ago but has not yet reviewed the documents. LPA explained the Accusation document and Mr. Dovlatyan agreed to go over the Accusation over the phone. As LPA began reading the Accusation for License Revocation, Revocation/Forfeiture of Administrator Certificate, and Exclusion Action, Mr. Dovlatyan stated that he does not want to go over this document over the phone. He stated that he will review it with his attorney and will contact the case LPA if he has any questions.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
	VISIT DATE: 11/18/2025

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LPA reminded Mr. Dovlatyan that the Accusation needs to be shared with residents, residents responsible persons, and is required to be posted in the facility in a prominent place. LPA shared and discussed the Health and Safety Code §1569.38 Posting of licensing reports; disclosure to new residents with Mr. Dovlatyan. Mr. Dovlatyan acknowledged understanding of the requirement.

During today's visit, the LPA did not observe any immediate health or safety concerns.

Exit interview conducted with Mr. Dovlatyan. Mr. Dovlatyan authorized staff to sign for today's report.
A copy of this report and the previous visit report dated 11/12/2025 was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025

LIC809 (FAS) - (06/04)

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