197608986-10-6-2025-29-AS-BBAI-DM7UL5-20251006154011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 10/06/2025
Date Signed: 10/06/2025 03:40:33 PM

Document Has Been Signed on 10/06/2025 03:40 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:	LALA SOGHOMONYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 6	DATE:	10/06/2025
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Lala Soghomonyan		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Brian Balisi and Martha Arroyo conducted an unannounced Plan of Correction (POC) visit to follow up regarding the plan of corrections that were due for submission. Upon arrival at approx 10:40 a.m. LPA's met with staff and explained the reason for the visit. Administrator Lala Soghomanyan was contacted and stated they will be at the facility in approx 30 mins. During required annual Continuation visit on 09/04/25,:LPAs cited the following: CCR 87309(a) with a due date of 09/05/2025 CCR 87411(a) with a due date of 09/05/2025 CCR 87405(d) with a due date of 09/05/2025 HSC 1569.69(a)(2) with a due date of 09/05/2025 CCR 87465 (a)(4) with a due date of 09/05/2025 CCR 87465 (a)(6) with a due date of 09/05/2025 CCR 87465(h)(2) with a due date of 09/05/2025 CCR 87208(a) with a due date of 09/12/2025 CCR 87706(a)(1)( C) with a due date of 09/12/2025 CCR 87307(a)(2)(B) with a due date of 09/12/2025 HSC 1569.618(c )(3) with a due date of 09/12/2025 CCR 87413 (a)(1) with a due date of 09/12/2025

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

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: 10/06/2025

NARRATIVE

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Continued from 9099

CCR 87412(g) with a due date of 09/12/2025
CCR 87411 (d) with a due date of 09/12/2025
CCR 87468(c )(2)(A) with a due date of 09/12/2025
CCR 87219 (a) with a due date of 09/12/2025
CCR 87555(b)(21) with a due date of 09/12/2025
CCR 87465(a)(8) with a due date of 09/12/2025
HSC 1569.695(c ) with a due date of 09/12/2025
CCR 87609(b)(4)(A) with a due date of 09/12/2025
CCR 87628(a) with a due date of 09/12/2025
CCR 87632(d)(2) with a due date of 09/12/2025
CCR 87633(h) with a due date of 09/12/2025
CCR 87705(b)(1) with a due date of 09/12/2025

On 09/05/2025 the Administrator initially sent the LPA an email for plans of corrections. On 09/17/2025, LPA reviewed documents and requested Administrator to update documents to clear pending deficiencies. As of today, the plans of corrections for deficiencies cited have not been cleared.

On 09/23/2025 during a Case Management - Other visit , LPA cited for the following:

CCR 87615 (a)(1) with a due date of 09/24/2025

During today's visit the LPA's observed the following:

LPA's observed Staff #1 (S1) briefly inside the facility then relieved by Staff #2 (S2).

Resident #1 (R1) was admitted to facility 10/05/2025. During the visit it was revealed resident records were not onsite to review, resident had not been administered their medications as prescribed and resident has a prohibited health condition.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

LIC809 (FAS) - (06/04)

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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: 10/06/2025

NARRATIVE

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Continued from 809-C

Resident #2 (R2) and Resident #3 (R3) have prohibited health conditions that were cited on 09/23/2025. As of today, R2 and R3 still reside in the facility.

Based on today's findings, Administrator did not demonstrate sufficient knowledge of staffing, resident care and facility daily business.

An immediate civil penalty of $56,250.00 is assessed today for failure to correct multiple citations. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted, deficiencies cited, civil penalties assessed, appeal rights discussed, and a copy of this report issued to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2025 03:40 PM - It Cannot Be Edited

Created By: Brian Balisi On 10/06/2025 at 03:03 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: 10/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2025 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	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 10/06/2025
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
Type A 10/07/2025 Section Cited CCR87405(d)	1 2 3 4 5 6 7	(d) the administrattor shall have the qulaifcations specified in section 87405(d)(1)through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	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 10/07/2025.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14

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: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

LIC809 (FAS) - (06/04)

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