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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 11/12/2025
Date Signed: 11/12/2025 01:46:16 PM

Document Has Been Signed on 11/12/2025 01:46 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AGE WELL ASSISTED LIVING FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR/
DIRECTOR:		NAILAH TATUMFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 2DATE:
11/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Sarkis DovlatyanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:15 AM to conduct an unannounced Case Management – Deficiencies visit at the facility today. LPA met with facility licensee representative Sarkis Dovlatyan entrance interview conducted and the reason for the visit was explained.

During today’s visit between 10:15 AM and 01:00 PM LPA conducted a physical plant tour, interviewed Staff #1 (S1), the licensee representative, and one (1) resident.

During the physical plant tour LPA observed the PUB 475 poster to be smaller than the required 20” x 26” size. LPA did not observe the personal rights or nondiscrimination notice to be posted in the facility. LPA did not observe a visible notice posted in a prominent location that states, “Section 680 of the Business and Professions Code requires health care practitioners to disclose their name and license status on a name tag in at least 18-point type while working in this facility.” LPA informed the licensee representative who stated that the personal rights, nondiscrimination notice, and complaint information were removed from the wall but were still present at the facility. The licensee representative agreed to post the required items along with an appropriately sized copy of the PUB 475 poster in the facility.

During today’s visit LPA had a conversation with the licensee representative and S1, LPA informed them that on 10/20/2025 Lala Soghomonyan, was served with an “Order to Individual for Immediate Exclusion from All Facilities” notice. LPA informed S1 and the licensee representative that Lala Soghomonyan may not be present at the licensed facility at any time. S1 and licensee representative expressed understanding and confirmed that Lala Soghomonyan would not be present at any time on the facility premises.

Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC809-D). Exit interview conducted and copy of the report and appeal rights were issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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 11/12/2025 01:46 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2025 at 01:20 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: 11/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
CCR
87605(c)

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87605 Health and Safety Protection
(c) ...shall post... “Section 680 of the Business and Professions Code requires...practitioners to disclose their name and license status on a name tag in at least 18-point type while working in this facility.”
This requirement is not met as evidenced by:
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The licensee representative agreed to post the required information in a prominent location no later than POC due date.
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Based on observation and interview the licensee did not comply with the section cited above as home health and other healthcare providers provide services to residents and the required posting was not present at the facility which poses a potential personal rights risk to clients in care.
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Type B
11/26/2025
Section Cited
CCR87468(d)

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87468 Personal Rights
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language... the residents can only read...
This requirement is not met as evidenced by:
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The licensee representative agreed to post the required information in a prominent location no later than POC due date.
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Based on observation and interview the licensee did not comply with the section cited above as the personal rights and nondiscrimination notice was not posted at the facility which poses a potential personal rights risk to clients 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2025 01:46 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2025 at 01:29 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: 11/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
CCR
87468(c)(2)(A)

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87468 Personal Rights
(c) Licensees shall prominently post...
(2) ... shall be posted as follows:
(A) ...(RCFE) Complaint Poster (PUB 475)...The poster that is posted shall be 20" x 26" in size...
This requirement is not met as evidenced by:
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The licensee representative agreed to post the required posting in an appropriate size in the entryway of the facility no later than POC due date.
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Based on observation and interview the licensee did not comply with the section cited above as the PUB 475 poster posted at the facility was smaller than the required size which poses a potential personal rights risk to clients 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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