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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 10/18/2024
Date Signed: 10/18/2024 01:35:49 PM

Document Has Been Signed on 10/18/2024 01:35 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:		SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 6DATE:
10/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Staff Zhyparkul MursamambetovaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20241014112146). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Staff Zhyparkul Mursamambetova and explained the reason for the visit. LPA contacted Licensee Sarkis Dovlatyan who stated they are unable to make the visit, but  stated staff can sign in their place.

During the investigation it was revealed that the facility did not submit a Special Incident Report (SIR) or death report to Community Care Licensing (CCL) to notify that Resident #1 (R1) was admitted to the hospital on 06/18/2024 and R1’s death in the hospital on 06/18/2024, in a timely manner. At approx 9:55 a.m. LPA conducted records review and did not observe any records kept onsite for R1.

A $1,000 immediate civil penalty is assessed today. The staff was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted, appeal rights discussed and copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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 10/18/2024 01:35 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/18/2024 at 12:37 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: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
87211(a)(1)(A)(B)

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Each licensee shall furnish to the licensing agency such reports... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The licensee agreed to submit a plan describing how they will ensure reporting requirements are followed and have administrator complete training in Reporting Requirement training. Submit proof to CCL by COB 10/21/2024.
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Based on records review, the licensee did not comply with the section cited above as Licensee did not submit an incident report on 04/13/2024 for R1's hospitalization, nor a death report on 05/09/2024 for R1, which posed a potential health and safety risk to residents in care.
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Type B
10/21/2024
Section Cited
CCR87506(b)(F)

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87506(b)(F) Each resident’s record shall contain at least the following information...(17) documents and information...(F)Section 87505, Documentation and support.
This requirement was not met as evidenced by:
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Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding of regulation cited and submit to LPA via email by EOD 10/25/2024.
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Based on records review for R1 resident records reviewed did not have a complete resident appraisal, physicians’ report, preplacement, and a needs and services plan. This poses a potential 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 Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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