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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/01/2025
Date Signed: 12/01/2025 02:06:34 PM

Document Has Been Signed on 12/01/2025 02:06 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:		NAILAH TATUMFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 2DATE:
12/01/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Sarkis Dovlatyan - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 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 10:45 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. 

On 11/13/2025, Accusation for License Revocation, Revocation / Forfeiture of Administrator Certificate, and Exclusion Action  was sent to Licensee of Age Well Assisted Living Facility.

On 11/18/2025, Zabel Chochian conducted a case management - other visit to ensure health and safety of residents in care. During that visit, LPA Chocian attempted to go over the accusation, however Licensee Sarkis Dolatyan stated they wanted to review with their attorney. LPA  reminded Mr. Dovlatyan that the Accusation needs to be shared with residents, residents responsible persons, and is required to be posted in the facility in a prominent place.  LPA shared and discussed the Health and Safety Code §1569.38 Posting of licensing reports; disclosure to new residents with Mr. Dovlatyan.  Mr. Dovlatyan acknowledged understanding of the requirement.

Per Health and Safety Code §1569.38(g), A licensee who fails to comply with the requirements of subdivision (b) or (c) shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). Today at  approx 11:00 a.m. did not observe accusation posted in a prominent place.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2025
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: 12/01/2025
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Between 11:00 a.m. - 3:00 p.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, snack and service.

On 11/25/2025, newly appointed  Administrator Nailah Tatum sent an email to LPA stating that they no longer work with Age Well Assisted Living. Today at approx 09:30 a.m. LPA contacted Tatum who confirmed they will not be moving forward with Age Well. LPA spoke with Licensee who stated Arshaluis "Lucy"  Manoukyan will be the new Administrator going forward.

On 11/28/2025, The Regional office received information that the heater in the facility stopped working and residents were going to be relocated to 8123 Paso Robles Ave , (All Star Living Inc #195850586). LPA's interview with residents revealed they were asked if they wanted to relocate , but they  did not want to relocate from this home. Space heater was provided to Resident #1(R1). Resident #2(R2) stated they did not want a space heater and that they preferred it to be cold. Both R1 and R2 did not express any concerns for temperature of facility at this time. During the visit, LPA observed the facility to be at a comfortable temperature.

At approx. 11:30 a.m. LPA reviewed caregiver background check on Guardian and observed status of Staff #1 (S1) to be "In-process". Licensee contacted another caregiver to relieve S1.  Staff #2 (S2) arrived at approx 01:00 p.m. LPA's interview with S1 and residents in care revealed S1 arrived to the facility this morning.

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D).  Civil penalties  in the amount of $1,400 will be assess today for failure to post accusation in a prominent place 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.

Exit interview conducted with licensee, appeal rights discussed and copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2025 02:06 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/01/2025 at 12:55 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: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2025
Section Cited
CCR
87355(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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S1 exited the facility during the visit and was relieved by S2. 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 12/02/2025.
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Based on observation and record review, the licensee did not comply with the section cited above as S1 was not associated , which poses an immediate health and safety risk to persons in care.
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Type A
12/02/2025
Section Cited
HSC1569.38(g)

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A licensee who fails to comply with the requirements of subdivision (b) or (c) shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day... (b) or (c) shall not exceed five thousand dollars ($5,000). This requirement was not met as evidenced by:
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Licensee posted Accusation letter during the visit. Licensee also agreed to review section 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 12/02/2025.
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Based on observations, the licensee did not comply with the section cited above as LPA did not observe accusations posted in a prominent place, which poses an immediate health, safety and 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: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2025 02:06 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/01/2025 at 01:30 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: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2025
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 by COB 12/02/2025.
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Based on interviews and records review the licensee did not comply with the section cited above as facility did not have an active administrator, which poses an immediate health, safety and 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: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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