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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 12/06/2021
Date Signed: 12/06/2021 07:12:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211201090238
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
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Dinah PascoTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are not wearing masks.
Facility is not following COVID-19 screening protocals.
INVESTIGATION FINDINGS:
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On December 6, 2021, at 11:05 a.m., Licensing Program Analysts (LPA's), Martha Guzman Chavez and KaSandra Lopez conducted an unannounced complaint investigation for the above allegations. LPA's were greeted at the door by staff, Wynn. The Administrator, Dinah Pasco, arrived at the facility at 12:04 p.m., and was explained the reason for the visit. Entrance interview conducted.

It was alleged that staff are not wearing masks. It was reported by the reporting party that while conducting an unannounced visit, they observed that the caregivers were not wearing masks. The LPA’s interviewed the Administrator and two staff between 11:10 a.m. and 1:15 p.m. and reviewed facility files at 12:30 p.m. Upon arrival to the facility, LPA’s observed the staff wearing masks inside the facility. However, interviews with staff revealed that while an outside agency came to visit, one of the staff was not wearing the mask properly. The caregiver admitted to having the mask on the chin. Interview with another staff further revealed that on a different occasion, while family members came to the facility, staff were also not wearing their masks properly. Based on interviews, the allegation of “staff are not wearing masks” is deemed Substantiated at this time. ...Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20211201090238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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...Continued from LIC 9099...

It was further alleged that facility is not following COVID-19 screening protocols. Upon entering the facility, the LPA’s were screened at the door and temperatures were taken by Staff. Although the LPA’s were screened, the LPA’s were not asked Covid-19 related screening questions. Furthermore, the LPA’s were not asked to sign in. Additionally, LPA’s observed a Home Health nurse coming into the facility at 11:00 a.m. However, upon record review, the LPA’s observed that the Home Health nurse had not signed into the visitor’s log showing that they had been screened for COVID-19. During staff interviews, staff reported that they were busy and had forgotten to have nurse sign in. Based on interviews and record review, the allegation of “facility is not following COVID-19 screening protocols” is deemed Substantiated at this time.

Citations Issued. See LIC 9099D. Appeal Rights discussed. Copy of the report emailed to Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20211201090238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations...

This requirement is not met as evidenced by:
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The Administrator will advise the staff on wearing masks at all times inside the faciltiy and conduct a training on CA Dept of Public Health Guidance for the use of face coverings issued/updated on 11/16/2020 and COVID-19 screening protocols and submit proof to LPA by 12/17/2021.
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Based observations and interviews, the Licensee did not ensure the personal rights of persons in care to live in a safe, healthy, and comfortable home as staff did not wear face coverings at all times while inside the facility and do not follow COVID-19 infection screening protocol, which poses 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211201090238

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
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Dinah PascoTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility not allowing visitations.
INVESTIGATION FINDINGS:
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It was alleged that the facility’s not allowing visitations. It was reported that there is a sign posted outside of the facility that states, “No Visitors”. Interview with the staff revealed that they were not aware of sign being posted outside of the facility stating, “No Visitors”. Furthermore, interviews with the staff revealed that residents’ family members are allowed to visit their family members at the facility. During the visit, Administrator removed sign and LPA’s obtained copies of the visitation log for the previous two (2) months. Upon record review, LPA’s observed that the visitation log showed there are visitors coming into the facility on the months of October and November. Based on interviews and record review, the allegation of “facility not allowing visitations” is deemed Unsubstantiated at this time.

Exit Interview. Copy of the report emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 4