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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 10/31/2025
Date Signed: 10/31/2025 01:14:24 PM

Document Has Been Signed on 10/31/2025 01:14 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:
10/31/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Devid DavydovTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit - other to ensure the health and safety of the residents in care. Upon arrival at approx 09:40 a.m., LPA met with staff and explained the reason for the visit. Licensee was contacted and stated they will be at the facility soon.

At approx 10:02 a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of facility documents. LPA observed a sufficient supply of perishable and non-perishable food properly stored at this time. LPA and staff inspected produce that was stored in fridge drawers. LPA observed produce to appear fresh and free of any signs of mold at this time.  Interviews with residents revealed they have been provided with sufficient meals and snacks since LPA's last visit on 10/27/2025 and residents did not express any concerns at this time.

On 10/16/2025, during a case management visit conducted from 9:30 a.m. to 4:00 p.m., LPA observed Staff #1 (S1) present inside the facility. At that time, S1 was not  associated. S1 was instructed to leave the facility.Today  the LPA received information indicating that S1 continued to provide services to residents in care. During interviews with Resident #1 (R1) and Resident #2 (R2), both residents stated that they have observed S1 on multiple evenings, sleeping in Bedroom #1, since the LPA’s visit on 10/16/2025

On 10/28/2025, the Licensee provided LPA with the following documents to update facility administrator:
Administrator Certificate  - exp 02/05/2027, LIC 308 ,LIC 501, LIC 503, Board Resolution , Criminal Record Statement, Employee rights. LPA requested licensee to update the following LIC 308, LIC 501 and LIC 503. Licensee stated they are waiting on the new administrator to complete and will send to LPA as soon as they receive them.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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: 10/31/2025
NARRATIVE
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Continued from 809

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D). Civil penalties in the amount of $2,000 will be assess today for failure to correct violation and repeat violations.

The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties. During the visit, the LPA did not observe any immediate health or safety concerns. Licensee contacted LPA at approx 11:20a.m. and stated they were unable to be onsite during the visit, but stated staff will sign in their place.

LPA conducted exit interview with Licensee over the phone along with staff onsite, 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: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 01:14 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/31/2025 at 12:16 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: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2025
Section Cited
CCR
87405(a)

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All facilities shall have a qualified and currently certified administrator... facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
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Licensee agreed to review section cited and email LPA with completed documents for new Administrator within 48 hours.
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Based on interviews and records review the licensee did not comply with the section cited above as the facility has not hired a qualified Administrator, which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
11/03/2025
Section Cited
CCR87355(e)(2)

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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:
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 Licensee agreed to review reg cited and submit a statement of understanding, an updated LIC 500 and a written plan on how they will ensure future compliance then send to LPA via email by COB 11/03/2025.
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Based on interviews and records 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.
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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: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 01:14 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/31/2025 at 12:27 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: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87307(a)(2)(B)

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(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:... storage area, shed or similar detached building. This requirement is not met as evidenced by:
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Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan to ensure future complaince and send to LPA via email by COB 11/07/2025.
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Based on interviews the licensee did not comply with the section cited above as upon arrival into facility, S1 stated they were sleeping, which poses/posed 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: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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