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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:32:56 PM


Document Has Been Signed on 12/28/2022 03:32 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
WOODLAND HILLS NORTH, 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: 6DATE:
12/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Villalyn Agustin, StaffTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst, Christine Yee, conducted a case management visit as a result of the deficiencies observed during a visit to the facility today. LPA Yee was allowed entry into the home by Alejandra Mendoza, Staff. The visit was conducted with Villalyn Agustin, Staff. The reason for today's visit was explained.

During the visit, LPA Yee observed the following deficiences
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  • the medication cabinet was left unlocked and unattended. Cabinet was locked when it was pointed out to staff by LPA Yee
  • Osana Keshishian, staff is at the facility 2 times a week to complete paperwork without obtaining a criminal record clearance and being associated to the facility
  • Khatchik Danielian, staff appointed as a designated backup administrator has not requested a criminal record clearance or exemption and is not associated to the facility. He has been observed at the facility.



Deficiencies are being cited under California Code of Regulations, Title 22, Chapter 6, Division 8. CIVIL PENALTIES are being assessed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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Document Has Been Signed on 12/28/2022 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2022
Section Cited

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87465(h)(2)INCIDENTIAL MEDICAL AND DENTAL CARE: the following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe
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The licensee shall ensure that all medications centrallly stored are kept in a locked cabinet and inaccessible to residents at all times. ****corrected at time of visit
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 place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met and poses a danger to the residents in care.
The medication cabinet was observed left unlocked and unattended
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/28/2022 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2022
Section Cited

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CRIMINAL RECORD CLEARANCES:
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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The Licensee will ensure that all staff have obtained a criminal record clearance and associated to the facility prior being present at the facility. Submit evidence that Osana Keshishian has obtained the
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Obtain a California clearance or a criminal record exemption as required by the Department or
Osana Keshishian, staff is at the facility to complete paperwork 2x a week withiout evidence of a criminal record clearance. This poses a danger to the residents in care.
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appropriate clearance by 12/29/22 and prior to being present at the facility.
Type A
12/29/2022
Section Cited

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CRIMINAL RECORD CLEARANCES:
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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The Licensee shall ensure that all individuals are cleared and have obtained an exemption prior to being present a the facility. Provide evidence that Khatchik Danielian has obtained the appropriate criminal record
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Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. Khatchik Danielian has not requested an exemption to be present at the facility. This poses a danger to the residents in care.
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clearances prior to being present at the facility by 12/29/22
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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