197608986-11-20-2025-29-AS-DPEA-DNR2KZ-20251124162847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 11/20/2025
Date Signed: 11/20/2025 03:13:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/20/2025 and conducted by Evaluator Trevor Byrne

COMPLAINT CONTROL NUMBER: 29-AS-20251120121920

FACILITY NAME:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR:	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:	11/20/2025
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Sarkis Dovlatyan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not afford a resident with dignity and respect by misrepresenting the availability of cleaning supplies.

There is insufficent cleaning supplies to ensure an adequate supply of clean dishes.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 10:01 AM. LPA met with facility Licensee Representative Sarkis Dovlatyan entrance interview conducted and the reason for the visit was explained.

During today’s visit LPA conducted a physical plant tour, and conducted interviews with the Licensee Representative, one (1) staff, and two (2) residents between approximately 12:15 PM and 01:40 PM.

Continued on LIC-9099C

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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-20251120121920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 11/20/2025

NARRATIVE

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The allegation of “There is insufficient cleaning supplies to ensure an adequate supply of clean dishes.” alleges that the facility did not maintain an adequate supply of dish soap to ensure clean dishes and utensils for resident use. During the physical plant tour LPA observed a bottle of dish soap located next to the kitchen sink. LPA observed a small amount of soap left in the bottle which appeared to be less than approximately one (1) centimeter of soap remaining. LPA observed the cleaning supplies under the kitchen sink and in the laundry room. LPA did not observe additional dish soap available at the facility. LPA observed one (1) side of the kitchen sink to contain dishes and utensils. Staff #1 (S1) informed LPA that the dishes had been rinsed but had not yet been washed. LPA observed the cabinets in the kitchen. LPA observed an adequate number of clean dishes including plates and bowls for more than one (1) day. LPA observed the utensils drawer to contain three (3) spoons, two (2) forks, and three (3) butter knives. LPA interviewed S1 who informed LPA that they notified the Licensee Representative of the low dish soap and other cleaning supplies on Tuesday 11/18/2025. LPA interviewed the Licensee Representative who stated that they were aware that the facility was running low on dish soap and cleaning supplies. Licensee Representative stated that they are informed by staff when supplies are running low and will place an order once they are informed. Licensee Representative stated that they do not check on supplies themselves. Licensee Representative stated that they had placed an order for delivery of dish soap, laundry detergent, and bleach to restock facility supplies. Licensee Representative provided LPA a photo of their amazon delivery orders showing three (3) bottles of Ajax liquid dish soap arriving tomorrow (11/21/2025). LPA observed this order to be placed on today’s date (11/20/2025). Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “There is insufficient cleaning supplies to ensure an adequate supply of clean dishes.” Therefore, the allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20251120121920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 11/20/2025

NARRATIVE

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The allegation of “Staff did not afford a resident with dignity and respect by misrepresenting the availability of cleaning supplies.” alleges that facility staff told a resident that there was additional dish soap stored at the facility in the washer/dryer room and not to worry about the low dish soap supply. One (1) resident interviewed, resident #1 (R1), stated that S1 assured them that there was extra soap available at the facility in the washer/dryer room. LPA interviewed S1 who denied telling facility residents that there was additional dish soap in the chemical storage. S1 stated that they informed residents that they would have to check if there was additional soap and if not, they would inform the owners to procure more. S1 stated that they informed residents that they would handle the issue and for the residents not to worry as this was an issue for them and the owner to handle. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not afford a resident with dignity and respect by misrepresenting the availability of cleaning supplies.” Therefore, the allegation is deemed Unsubstantiated at this time.

The Licensee Representative was unable to come to the facility at the time this report was issued but has allowed S1 to receive and sign this report on their behalf. A copy of the report was printed, appeal rights were provided, and exit interview was conducted with S1.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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