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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/11/2025
Date Signed: 12/11/2025 01:44:21 PM

Document Has Been Signed on 12/11/2025 01:44 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:
12/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator - Arshalouis ManoukianTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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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 10:40 a.m.,  LPA met with staff and explained the reason for the visit. Licensee was contacted and stated they can be present at the visit later in the day.  The tentative new Administrator Arshalouis Manoukian arrived shortly after. At approx 09:50 a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of facility documents. LPA observed Accusation for License Revocation, Revocation / Forfeiture of Administrator Certificate, and Exclusion Action posted on the wall in the office area.

At approx 09:51 a.m.  LPA observed cucumbers with mold and Cabbage that appeared to be extremely brown.  Administrator discarded produce right away. LPA observed a sufficient supply of non-perishable food properly stored at this time in the pantry. Common areas, restroom and resident bedrooms observed clean and odor free.  Residents were interviewed.  Interviews with residents revealed they have been provided with sufficient meals and snacks since the last inspection visit on 12/01/2025 and residents did not express any concerns at this time. Residents also stated they were aware of the accusation that was posted on 12/01/2025.

During LPA Trevor Byrne's Pre-Licensing Visit on 11/20/2025 for Age Well Assisted Living #195850516, the following was notated:
LPA did not observe an auditory alarm installed on the front gate as required by 87705(d).
LPA did not observe the personal rights of residents posted in the facility as required by 87468(d).
LPA did not observe the required healthcare practitioners notice posted in the facility as required by  87605(c).
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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: 12/11/2025
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Continued from 809.
LPA was also unable to review the facility’s updated emergency disaster plan to review the corrections that were identified in the previous  pre-licensing inspection.

Today LPA observed the following:
LPA observed auditory alarm to be functioning when Administrator opened and closed front entry gate.
LPA observed personal rights form to be posted by entry way.
LPA observed an updated emergency disaster plan kept in a facility file. Administrator posted plan by entry way.
LPA observed new camera's installed, but were not functioning at this time.

At approx 10:30 a.m. LPA did not observe the required healthcare practitioners notice posted in the facility as required by  87605(c). 

At approx 11:30 a.m. LPA conducted medication review for Resident #1 (R1). Medication review revealed R1's Centrally stored medication list has not been updated for December 2025.

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D). The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties.

Licensee was contacted and stated they were not able to be onsite at this time.

Exit interview conducted with Administrator, 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: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 01:44 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/11/2025 at 12:46 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: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
CCR
87465(h)(6)

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The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes...: This requirement was not met as evidenced by:
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Administrator agreed to update Centrally stored Medication list and review section cited then provide LPA with a written plan to ensure future compliance by COB 12/12/2025.
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Based on records review, Centrally stored medication list for R1 (R1) had not been updated for December 2025, which is an immediate health, safety and personal rights risk to persons in care.
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Type B
12/19/2025
Section Cited
CCR87605(c)

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Licensees who employ or permit health care practitioners... 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.” This requirement was not met as evidenced by:
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Administrator agreed to post statement by entryway. They also agreed to review section cited and provide LPA a statement of understanding by POC 12/19/2025.
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Based on observations, the LPA did not observed required healthcare practitioners notice posted in the facility, which is 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: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 01:44 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/11/2025 at 12:50 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: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87555(b)(8)

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All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by:
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Administrator discarded produce right away and agree to review section cited and provide LPA a written plan to ensure future compliance by COB 12/19/2025.
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Based on observations, LPA observed cucumbers to have mold and cabbage to be browned which is a potential health, safety or personal rights risks 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: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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