<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:34:09 PM

Document Has Been Signed on 10/16/2025 03:34 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: 2DATE:
10/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 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 Analysts (LPAs) Brian Balisi and Martha Arroyo conducted a Case Management - Deficiencies visit to address deficiencies observed during an unrelated complaint investigation. Entrance interview conducted.

At approximately 9:50 a.m., the LPAs conducted a physical plant tour to ensure there were no health or safety concerns. During the tour, at approximately 9:55 a.m., the LPAs observed an individual sleeping in Bedroom #1. Interviews revealed that the individual had been working evening shifts at the facility for the past three days. However, the LPAs reviewed the list of individuals associated to the facility and did not observe Staff #1 (S1) on this list. The Administrator stated that the individual had been hired to perform housekeeping duties and was unaware that fingerprint clearance was required for S1. S1 left the premises during the LPAs’ visit.

Additionally, the Administrator reported that Staff #2 (S2) is responsible for providing care and supervision to residents during the night shift. A review of S2’s personnel file revealed that their most recent first aid certification was completed in 2019, and the last documented training occurred in 2020. Administrator was not aware that S2 was still in the facility.

Interviews further revealed that four (4) residents were transported to the hospital via ambulance on 10/07/2025 and 10/08/2025. However, a review of the facility’s records showed that incident reports were not submitted to the Department within the required seven (7) days of the occurrences, as mandated by reporting regulations. Administrator provided reports for (2) residents and was reminded to provide the other (2) reports , but they are still pending.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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)
Page: 2 of 7
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: 10/16/2025
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
26
27
28
29
30
31
32
Moreover, it was found that some residents have been refusing prescribed medications, yet the facility failed to notify either the residents’ physicians or the Department regarding these refusals.

Furthermore, on 10/06/2025, the LPAs were informed that the Community Care Licensing Division (CCLD) Investigations Branch (IB) had contacted the Administrator and requested documentation related to an open investigation. The LPAs spoke with the Administrator to reiterate the importance of submitting the requested documentation. As of today, the requested documents have not been submitted to the CCLD Investigations Branch.

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D).

Civil penalties in the amount of will be assessed today due to repeat violations for citations: Criminal Record Clearance – 87355(e)(2) from 10/06/2025, and Administrator Qualifications and Duties – 87405(d) (d) from 09/04/2025.

The Administrator was informed that failure to correct the deficiencies may result in additional civil penalties.

Administrator left during the visit to attend to a personal matter and stated they would not be able to return to the visit. Licensee was contacted and stated they are unable to be onsite.



Exit interview conducted with Staff and Licensee, appeal rights discussed, and a copy of this report issued
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/16/2025 03:34 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/16/2025 at 02:05 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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2025
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
Criminal Record Clearance: All individuals subject to a criminal record review ...(b) shall prior to working... in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department…This requirement was not met as evidenced by:
1
2
3
4
5
6
7
S1 exited the facility during the visit. Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/17/2025.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above as a criminal background fingerprint clearance was not conducted for S1, which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type A
10/17/2025
Section Cited
CCR87755(b)

1
2
3
4
5
6
7
Inspection Authority of the Licensing Agency (b) The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
 Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/17/2025.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above as they have not submitted any documents requested by the Community Care Licensing Investigations Branch, which poses an immediate health and safety 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: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/16/2025 03:34 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/16/2025 at 02:09 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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
87415(a)

1
2
3
4
5
6
7
The following persons providing night supervision from l0:00 p.m. to 6:00 a.m... shall be available as indicated below to assist in caring for residents in the event of an emergency. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
 Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/24/2025.
8
9
10
11
12
13
14
Based on record review, the Licensee did not comply with the section cited above as the nocturnal staff does not have first aid certification on file, which poses a potential health and safety risk to persona in care.
8
9
10
11
12
13
14
Type B
10/24/2025
Section Cited
CCR87411(c)

1
2
3
4
5
6
7
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
 Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/24/2025.

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/16/2025 03:34 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/16/2025 at 02:12 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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
87211(a)(1)(D)

1
2
3
4
5
6
7
Each licensee shall furnish to the licensing agency such reports as the Department may require... Any incident which threatens the welfare, safety or health of any resident or unexplained absence of any resident. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/24/2025.
8
9
10
11
12
13
14
Based on record review, the Licensee did not comply with the section cited above as (4) residents were sent out to the hospital on 10/07/25 and 10/08/25 and have not sent all incident reports to the Department, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/16/2025 03:34 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/16/2025 at 02:26 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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2025
Section Cited
CCR
87405(d)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 10/17/2025.
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, availability and qualifications as an Administrator, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7