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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 09/23/2025
Date Signed: 09/23/2025 02:43:31 PM

Document Has Been Signed on 09/23/2025 02:43 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/
DIRECTOR:		LALA SOGHOMONYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 4DATE:
09/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Lala SoghomonyanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - other visit.  LPA met with individual/staff and explained the reason for the visit. LPA contacted Administrator Lala Soghomonyan  who stated they will be at the facility for the visit.
At approximately 09:35 a.m., LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent facility documents relevant to the visit.
At approx 10:00 a.m. LPA spoke with a home health nurse conducting a visit with Resident #1 (R1). Home health nurse stated they had difficulty getting hold of staff to enter the facility. Interview with R1 confirmed the phone rang multiple times this morning, but staff was busy providing assistance to another resident.
LPA interview with four (4) residents in care  revealed they were  satisfied with the service and food at this time.  LPA observed a sufficient supply of perishable and non-perishable food properly stored during today's visit. At approx 11:47 a.m. LPA observed Administrator bring in extra groceries and specific items requested by residents. Administrator also arrived with a reliever staff who was fully cleared and associated to the facility. 
LPA's review of California Department of Social Services criminal clearance record database revealed that staff #1 (S1)  is not fingerprint cleared to work. Interviews and records review confirmed that S1 started working at this facility today.

Following deficiencies were cited from the Title 22 California Code of Regulations on 809-D.  Civil penalty issued today in the amount of $1,100 for staff not finger print cleared and a repeat violation. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed and a copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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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Document Has Been Signed on 09/23/2025 02:43 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/23/2025 at 01:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2025
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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Administrator obtained reliever for S1 to cover shift .Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 09/24/2025.
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Based on observation, interview and record review, the Licensee did not comply with section cited above as S1 is not fingerprint cleared, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/24/2025
Section Cited
CCR87615(a)(1)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be 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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Administrator agreed to relocate R1 and provide proof to LPA. Administrator also agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 09/24/2025.
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Based on interviews and record review, the Licensee did not comply with section cited above as R1 has a stage 3 wound on their left ankle, and R4 has a stage 4 wound on hip, which poses an immediate 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2025 02:43 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/23/2025 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by
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Staff cleaned kitchen during the visit. Administrator agreed to review section cited and create a plan on how they will ensure to keep future compliance the send to LPA via email COB 10/03/2025.
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Based on observation the licensee did not comply with section cited above as LPA observed multiple dirty dishes on the counter, left over food on dining table and flies hovering in the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/03/2025
Section Cited
CCR87411(a)

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Facility personnel shall at all times be sufficient in numbers...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:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 10/03/2025.
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Based on interviews, the licensee did not comply with the section cited above as staff was unable to be readily availble to open the door for a home health nurse as staff was assisting a resident, which poses a potential health, safety or personal rights risk for 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2025 02:43 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/23/2025 at 01:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2025
Section Cited
CCR
87405(d)

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(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:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 09/24/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above as the Administrator did not demonstrate sufficient knowledge of new staff and new resident, which poses an immediate health, safety or personal rights risk to residents in care.
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Type B
10/03/2025
Section Cited
CCR87412(g)

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87412(g) - All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 10/03/2025.
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Based on records review, the licensee did not comply with the section cited above as S1 did not have a complete file onsite for review, 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/23/2025 02:43 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/23/2025 at 01:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
CCR
87609(b)(4)(A)

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(4) The licensee and home health agency agree in writing on the responsibilities...(A)The written agreement shall reflect the services, frequency and duration of care. This requirement was not met as evidenced by:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 10/03/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above as R1, R2, R3 are on homehealth, but there were no records onsite available to review, which poses a postential health, safety or personal rights risk to residents in care.
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Type B
10/03/2025
Section Cited
CCR87211(a)(1)

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(1)A written report shall be submitted to the licensing agency and to the person responsible... (A) through (D) below... attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 10/03/2025.
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Based on records review, facility has not submitted any incident reports or death reports, which poses a potential health, safety or personal rights 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/23/2025 02:43 PM - It Cannot Be Edited


Created By: Brian Balisi On 09/23/2025 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
CCR
87457(c)

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Prior to admission a determination of the prospective resident's suitability for admission... with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement was not met as evidenced by:
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Administrator agreed to review section cited and create a written plan on how they will ensure future compliance then send to LPA via email COB 10/03/2025.
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Based on records review LPA did not observe any pre-admission documentation on site for review for R4, which poses a potential health, safety or personal rights 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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