<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/06/2021
Date Signed: 12/06/2021 08:04:43 PM

Document Has Been Signed on 12/06/2021 08:04 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:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Dinah PascoTIME COMPLETED:
06:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) KaSandra Lopez and Martha Guzman-Chavez conducted an unannounced Case Management - Deficiencies report due to deficiencies observed during the complaint investigation of complaint control #29-AS-20211201090238 beginning at 11:05 AM. At 11:33 AM Dinah Pasco who was identified as the Administrator by the caregiver, was contacted and the LPAs spoke with her and advised her of the reason for today's inspection. The LPAs met with Dinah Pasco at 12:05 PM at the facility. At 12:32 PM the LPAs spoke with Licensee Representative Sarkis Dovlatyan on the telephone and explained to him the reason for the inspection also. Licensee Representative confirmed Dinah Pasco was the new Administrator and stated the paper for the change had been submitted.

During the complaint investigation, it was observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not associated to the facility. Interviews with S1, S2, and S3 revealed each staff have worked at the facility for more than five days. Therefore, civil penalties will be assessed in the amount of $500 ($100 a day x 5 days) each for S1, S2, and S3.

Resident record review was conducted for three of the five residents beginning at 1:52 PM. Record review revealed, Resident #1 (R1) did not have a completed facility file, including signed admission agreement, medical assessment, emergency identification, signed personal rights, or appraisal on file. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) was missing the rate for basic services on their signed admission and did not have a medical assessment on file, and Resident #3 (R3) did not have a signed admission agreement on file.

At 5:57 PM, Licensee Representative Sarkis Dovlatyan was contacted via telephone to go over the report and to discuss the following. On approximately 04/09/2015, Corporation Age Well Assisted Living, Inc. listed Sarkis Dovlatyan as 100% owner of the corporation. Report continued on LIC 809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 12/06/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
California Secretary of State records reflect on 09/12/2021 the Chief Executive Officer of the corporation was listed as Oganes Duymalyan, although California Secretary of State records now reflect Sarkis Dovlatyan as the Chief Executive Director again as of 11/17/2021.

The LPAs discussed with Mr. Dovlatyan the change of the Chief Executive Officer for the corporation, and the change back to Mr. Dovlatyan. Mr. Dovlatyan understands that a transfer of the majority of stock constitutes a majority change in ownership which would be considered a forfeiture of license. Mr. Dovlatyan understands by doing so, the facility would be considered operating unlicensed. Mr. Dovlatyan stated he was not aware of the change of Chief Executive Director until the SBA advised him of this and stated he did not know who Oganes Duymalyan was.

Mr. Dovylatyan stated a new applicant has applied for licensure at this location, but understands he is still responsible for the operation of the facility until the new license is approved and that a license cannot be sold or transferred to another individual or entity.

The LPAs also advised Mr. Dovlatyan that in the matter of Anna Hakobyan, a Decision and Order that became effective September 30, 2021 excludes Anna Hakobyan from any care facility licensed by the Department pursuant to Health and Safety Code 1569.58. Excluding Anna Hakobyan from being a licensee, owning a beneficial ownership interest of 10% or more in a licensed facility, or being an administrator, officer, director, member, or manager of a licensee or entity controlling a licensee, and, further, from all care facilities licensed by the Department, for the remainder of her life, unless she successfully petition for reinstatement or reduction of penalty. A copy of the Accusation dated 10/31/2018, and the Decision and Order were given to the parents of Mr. Dovlayton who live in the back house on the property per his request.

Exit interview and report reviewed with Mr. Dovlatyan. Administrator Dinah Pasco signed the report. A copy of the report, appeal rights, Accusation, and Decision and Order will be emailed to Mr. Dovlatyan.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2021 08:04 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/06/2021 at 04:23 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: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2021
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant....(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall update in Guardian or submit the LIC 9182, LIC 508 and a copy of the photo ID to the Woodland Hills North Regional office for S1, S2, and S3. Civil penalties shall continue to accrue until the plan of correction is cleared.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee failed to comply with the section cited above as three staff (S1, S2, and S3) criminal record clearances were not transferred to the facility which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
12/13/2021
Section Cited
CCR87507(a)(g)(A)

1
2
3
4
5
6
7
87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee/Administrator shall submit proof R1 and R3 has a completed and signed admission and agreement and R2 has a completed admission agreement with the basic rate listed to CCLD by 12/13/2021.
8
9
10
11
12
13
14
Based on record review, the licensee failed to comply with the section cited above as three residents (R1, R2, R3) out of three files reviewed, revealed R1 and R3 did not have a signed admission agreement and R2's admission agreement was not complete which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/06/2021 08:04 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 12/06/2021 at 04:43 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: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2021
Section Cited
CCR
87458(a)

1
2
3
4
5
6
7
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89)... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee/administrator shall submit proof R1 and R2 have a medical assessment signed by a physician within the last year, to CCLD by 12/20/2021.
8
9
10
11
12
13
14
Based on record review, the licensee failed to comply with the section cited above, as two residents (R1 & R2) out of three residents did not have a medical assessment on file which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
12/13/2021
Section Cited
CCR87506(a)

1
2
3
4
5
6
7
87506 Resident Records (a) 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 is not met as evidenced by:
1
2
3
4
5
6
7
The licensee/administrator shall submit proof R1 has a completed file, including but not limited to, identification and emergency information, appraisal, signed personal rights form to CCLD by 12/13/2021.
8
9
10
11
12
13
14
Based on record review, the licensee failed to comply with the section cited above, as one resident (R1) out of three residents did not have a completed facility file which poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4