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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/19/2025
Date Signed: 12/19/2025 01:31:11 PM

Document Has Been Signed on 12/19/2025 01:31 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:
12/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Arshalouis ManoukianTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Brian Balisi and Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250620153333). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation unrelated to the complaint. Upon arrival, LPAs met with staff and explained the reason for the visit. LPA's contacted Licensee Sarkis Dovlatyan who stated they will contact their Administrator Arshalouis Manoukian. Manoukian arrived shortly after.

On 06/20/2025, the Department received a complaint alleging questionable death of Resident #1 (R1). The case was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB) and assigned to Investigator Michele Salant. On 09/15/2025, the RO obtained copies of Emergency Medical Service (EMS) reports along with 9-1-1 audio recordings and transcripts for the facility dating back to six (6) months. A review of the EMS reports, 9-1-1 recordings and transcripts revealed two (2) additional questionable deaths, Resident # 2 (R2), Resident #3 (R3), that were not reported to the department.

According to the EMS reports reviewed, upon paramedics’ arrival on 05/16/2025 at 9:58 a.m., R2 was noted to be unconscious, cold to touch, in lividity and Dead on Arrival (DOA). Per the facility staff, R2 was last seen approx. 14 hours prior. Staff observed R2 to be unresponsive and not breathing in the morning when attempting to change R2s diaper. Moreover, according to EMS, it was notated that the resident was found in supine position, laying in bed in a state of “rigor, as well as lividity.” On 05/30/2025 at 11:03 a.m., Paramedics arrived at the facility and observed R3 unresponsive, pale, DOA in obvious rigor and lividity. Staff noted that R3 was last seen approx. 5 hours ago.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2025
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: 12/19/2025
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Furthermore, during the course of the complaint investigation it was revealed that on 06/18/2025, Los Angeles Fire Department (LAFD) arrived at the facility for a deceased individual, who was identified by staff as R1. However, the complaint investigation reflected that the deceased individual was in fact Resident #4 (R4) and staff provided LAFD with incorrect information. R1 was observed alive and well living at a different facility. Per EMS report, upon arrival R4 was already in a state of rigor and lividity. Based on paramedics’ assessment, the state of rigor and lividity indicates R4 had been deceased for more than a minimum of an hour. Flies were seen in the residents’ mouth and nose, and facility had bare minimum care equipment on site. Staff were unable to provide any information regarding the resident to emergency personnel and informed them that R4 was seen alive 10 minutes prior, which is contradictory to how R4 was discovered by EMS.
Investigator Salant made several attempts on 09/30/2025, 10/02/2025, 10/03/2025 and 10/14/2025 to obtain facility records for all four (4) residents from facility administrator, Lala Soghomonyan. On 09/24/2025, Investigator Salant requested records from the licensee representative, Sarkis Dovlatyan, who provided hospice records dated with the same date they were requested even though the residents had been deceased prior to the requested date. Facility administrator also denied R4 was a resident at the facility.
The Facility Administrator and licensee failed to maintain complete and accurate resident records, including care documentation, monitoring records, and medical records, for residents R2, R3, and R4. Hospice records for R2 were provided only after request and could not be verified as accurate or complete. The lack of required documentation prevented the Department from determining the care, supervision, and health-related services provided prior to the residents’ deaths. Additionally, the licensee failed to ensure sufficient and competent staff were present and adequately trained to meet residents’ needs. Staff failed to conduct routine welfare checks, failed to recognize changes in residents’ conditions, and provided inconsistent and contradictory statements regarding resident observations.

The following deficiencies were cited from the Title 22 California Code of Regulations. (See LIC 809-D).  Civil penalties  in the amount of $500 will be assess today for repeat violations. The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties.


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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/19/2025 01:31 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/19/2025 at 10:18 AM
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: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2025
Section Cited
HSC
1569.312(a)

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§1569.312(a) Basic services requirements. Basic services shall at a minimum include:(a)Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:
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Licensee will submit a plan how you will ensure appropriate care and supervision to residents. Submit to CCL via email by due COB 12/22/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above as Facility staff did not provide sufficient care and supervision to R2, R3 and R4 which resulted in their death’s, which posed an immediate health and safety risk to residents in care.
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Type A
12/22/2025
Section Cited
CCR87466

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The licensee shall ensure that residents are regularly observed for changes in physical...brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Licensee will submit a plan how you will ensure sufficient observations are conducted to residents in care then submit to CCL via email by 12/22/2025.
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Based on interviews and records review, the licensee did not comply with the section cited above as Facility staff did not provide sufficient observation to R2, R3 and R4, which posed an immediate health and safety 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: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2025 01:31 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/19/2025 at 10:25 AM
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: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2025
Section Cited
CCR
87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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Licensee agreed keep full facility files, review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 12/22/2025
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Based on interviews and records review the Licensee did not comply with the regulation cited above as the Licensee failed to maintain full and accurate resident records , which posed an immediate health, safety and personal rights risks to persons in care.
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Type A
12/22/2025
Section Cited
CCR87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 12/22/2025
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Based on interviews and records review the Licensee did not comply with the regulation cited above as the Licensee provided false information to LAFD, which posed an immediate health, safety and 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: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2025 01:31 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/19/2025 at 10:52 AM
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: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2025
Section Cited
CCR
87211(a)(1)(A)

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Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not met as evidenced by:
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Licensee agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 12/22/2025.
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Based on interviews and records review the Licensee did not comply with the regulation cited above as Death Reports were never provided to the RO for R2, R3 and R4, which posed an immediate health, safety and personal rights risks to persons in care.
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Type A
12/22/2025
Section Cited
CCR87411(a)

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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by:
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Licensee agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 12/22/2025.
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Based on interviews and records review the Licensee did not comply with the regulation cited above as staff failed to observe residents’ condition, resulting in deaths occurring unnoticed, which poses an immediate health, safety and 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: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2025


LIC809 (FAS) - (06/04)
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