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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 11/12/2024
Date Signed: 11/12/2024 04:58:00 PM

Document Has Been Signed on 11/12/2024 04:58 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AGE WELL ASSISTED LIVING FACILITYFACILITY NUMBER:
197608986
ADMINISTRATOR/
DIRECTOR:		LALA SOGHOMONYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Lala SoghonyanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 11:32 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Administrator Lala Soghonyan. The LPA advised the Administrator of the reason for the visit.

During the physical plant tour at 11:36 AM LPA observed the sliding door in the living room of the facility to be missing an auditory alarm. LPA informed the administrator who agreed to install a replacement alarm. At 11:40 AM LPA observed the living room pantry to contain three (3) expired and/or damaged food cans as well as one (1) unsecured box of prescription lancets. LPA informed the administrator who secured the items immediately. At 11:52 AM LPA observed an unsecured shed in the back of the facility. LPA observed the shed to contain tools, cleaning supplies and extra care supplies. LPA informed the administrator who agreed to secure the shed. At 02:40 PM LPA observed the facility’s first aid kit. The kit was observed to be missing Sterile first aid dressings, bandages or roller bandages, scissors, tweezers, and a current version of a first aid manual. The entire property is not fenced and is connected to three (3) adjacent properties. A certificate of occupancy was requested for this property and the adjacent three (3) buildings on the property.

During file review at 12:18 PM LPA observed four (4) of five (5) resident files to be missing signatures on documents including but not limited to: admission agreements, consent forms, identification and emergency contact information, appraisal needs and services, and property and valuables. LPA informed the administrator who agreed to get the signatures of the responsible parties of each resident on all identified forms. LPA observed one (1) staff file to be missing the required annual trainings. LPA informed the administrator who agreed to conduct the required trainings with the identified staff member.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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 11/12/2024 04:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2024 at 03:25 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited
CCR
87507(j)

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87705 Care of Persons with Dementia
(j) - The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
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Administrator agreed to purchase and install a new auditory alarm. Administrator will submit proof of installation to CCLD no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as one sliding door was observed to be missing an auditory alarm which poses a potential safety risk to clients in care.
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Type B
11/26/2024
Section Cited
CCR87506(b)

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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
This requirement is not met as evidenced by:
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Administrator agreed to get the required signatures from resident's responsible parties on all identified documents. Administrator will submit proof to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as four of five resident files were missing required signatures on required documents which poses a potential safety and personal rights risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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Document Has Been Signed on 11/12/2024 04:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2024 at 03:37 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2024
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (5) Under no circumstances.... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a... plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Administrator agreed to remove the full bed rails from the identified resident's bed. Administrator may submit a physician's order for full bed rails to CCLD.
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Based on observation and record review the licensee did not comply with the section cited above as one resident's bed contained full bed rails and did not have an order which poses a potential personal rights risk to clients in care.
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Type B
11/26/2024
Section Cited
CCR87465(a)(8)

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87465 Incidental Medical and Dental Care
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained... shall contain at least the following:
This requirement is not met as evidenced by:
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Administrator agreed to purchase a new first aid kit. Administrator will submit proof of new first aid kit purchase to CCLD no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as the facility first aid kit was observed to be missing sterile dressings, roller bandages, scissors, tweezers, and a first aid manual which poses a potential health and safety risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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Document Has Been Signed on 11/12/2024 04:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2024 at 03:50 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications...is maintained...
This requirement is not met as evidenced by:
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Administrator agreed to complete a medication audit and to log all medications properly on their respective CSMDR. Administrator will submit proof to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as two of three resident's medications were not properly logged on their CSMDR which poses a potential health and safety risk to clients in care.
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Type B
11/26/2024
Section Cited
CCR87507(c)

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87507 Admission Agreements
(c) Admission agreements shall be signed and dated...no later than seven days following admission...
This requirement is not met as evidenced by:
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Administrator agreed to have all identified admission agreements signed by resident's responsible parties. Administrator will submit proof to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as two of four resident's admission agreements were not signed by their responsible parties which poses a potentialpersonal rights risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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Document Has Been Signed on 11/12/2024 04:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2024 at 04:08 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited
CCR
87555(b)(8)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality... Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
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Administrator will conduct an audit of all facility food and will dispose of any expired food items. Administrator will submit proof to CCLD no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as three expired / damaged food cans were observed in the pantry which poses a potential health risk to clients in care.
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Type B
11/26/2024
Section Cited
HSC1569.625(b)(2)

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-1569.625 - (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...
This requirement is not met as evidenced by:
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Administrator agreed to conduct trainings with the identified staff member and will submit proof of completion to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above asone staff member was observed to lack the required annual trainings which poses a potential health, safety, and personal rights risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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Document Has Been Signed on 11/12/2024 04:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/12/2024 at 04:14 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
87705(f)

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(f) The following shall be stored inaccessible to residents with dementia: (1) ... tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication... alcohol, cigarettes, and... cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Administrator agreed to secure the shed. Administrator will submit proof to CCLD no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as LPA observed an unlocked shed in the backyard to contain cleaning supplies and tools which poses an immediate health and safety risk to clients in care.
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Type A
11/13/2024
Section Cited
CCR87465(h)(2)

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87465 (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
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Administrator secured the lancets at the time of the visit POC cleared.
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Based on observation the licensee did not comply with the section cited above as LPA observed an unsecured box of perscription lancets in the pantry closet which poses an immediate health and safety risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AGE WELL ASSISTED LIVING FACILITY
FACILITY NUMBER: 197608986
VISIT DATE: 11/12/2024
NARRATIVE
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During medication review at 01:21 PM LPA observed two (2) of three (3) residents files to have their medications incorrectly logged on their respective centrally stored medication and destruction record sheets. LPA informed the facility administrator who agreed to conduct a medication audit and to update the centrally stored medication and destruction record sheets for the identified residents.

The Administrator was unable to sigh the report at the time it was delivered but has designated facility manager Iveta Darabedyan to sign on their behalf.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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