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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/30/2025
Date Signed: 12/30/2025 12:50:11 PM

Document Has Been Signed on 12/30/2025 12:50 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:
12/30/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Arshalouis Manoukian TIME VISIT/
INSPECTION COMPLETED:
01:00 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 09:30 a.m.,  LPA met with staff and explained the reason for the visit.  LPA contacted Licensee Sarkis Dovlatyan who stated they can be availble later today. Administrator Arshalouis Manoukian arrived shortly after.
At approx 9:45 a.m. LPA conducted physical plant, interviewed staff and residents the following was observed:
At approx 09:50 a.m., LPA did not observed a sufficient supply of perishable foods stored in fridge. No milk, no eggs and no vegetables. Administrator stated the groceries will be delivered today. Leftover foods were observed to be properly sealed, and labeled. At approx 09:51 a.m  LPA observed a lock on pantry door closet making non-perishable foods not readily accessible to residents in care. At approx 10:12am - LPA observed Resident #1 (R1) , unlock medication cabinet and administer own medications. LPA's interview with Staff #1 (S1), revealed that this past weekend, R1  has been refusing assistance with their medications. Between 09:45 a.m. 01:00 .m. LPA conducted  interviews with R1, R2 and S1. These interviews  revealed staff has been sleeping in the common area overnight since 12/28/2025.

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 rep 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: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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 12/30/2025 12:50 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/30/2025 at 11:40 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: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2025
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Licensee representative spoke with R1 regarding their access to medication. Licensee also agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 12/31/2025.
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Based on interviews and observations the Licensee did not comply with the regulation cited above as the R1 was observed accessing the centrally stored medication cabinet , which posed an immediate health, safety and personal rights risks to persons in care.
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Type B
01/09/2026
Section Cited
CCR87555(b)(26)

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87555 (b)(26) - Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Licensee rep had groceries delivered today. Licensee rep also agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 01/09/2026.
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Based on observations, the Licensee did not comply with the regulation cited above as the Licensee failed to maintain a sufficient supply of foods such as milk, eggs, and produce, which posed a potential 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: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/30/2025 12:50 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/30/2025 at 11:45 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: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
87468.1(a)(3)

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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:
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Licensee rep agreed to have locked removed today. Licensee rep also agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 01/09/2026.
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Based on observations, the Licensee did not comply with the regulation cited above as pantry for non-perishable foods was observed locked, which posed a potential health, safety and personal rights risks to persons in care
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Type B
01/09/2026
Section Cited
CCR87307(a)

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The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility...This requirement is not met as evidenced by:
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Licensee rep agreed to review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 01/09/2026.
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Based on interviews, the licensee did not comply with the section cited above as S1 has been sleeping on the couch in the living room which poses a potential 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: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/30/2025 12:50 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/30/2025 at 11:52 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: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
87411(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...additional staff for the provision of adequate services. This requirement is not met as evidenced by:
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Licensee rep agreed to provide an updated LIC 500 then review regulation cited and provide a written plan to ensure future compliance then provide to LPA via email by COB 01/09/2026.
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Based on interviews, the licensee did not comply with the section cited above as S1 has been working since 12/28/2025 with no break which poses a potential 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: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
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