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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 12/30/2024
Date Signed: 12/30/2024 12:52:20 PM

Document Has Been Signed on 12/30/2024 12:52 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:		LALA SOGHOMONYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 4DATE:
12/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Sarkis Dovlatyan - LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA Brian Balisi conducted a Case Management - Deficiencies visit report during the investigation of Complaint Control #29-AS-20231108131542. Reason for this report is to issue deficiency observed during the complaint investigation which were unrelated to the complaint allegation. During today’s visit, LPA met with Staff and explained the reason for the visit. Licensee Sarkis Dovlatyan arrived shortly after.

During records review, LPA did not observe a Centrally stored medication log in Resident #1’s (R1) and a LIC 624 was not submitted to the Department for R1’s hospitalization on 11/01/2023

A Repeat Violation Civil Penalty is assessed in the amount $250.00 for deficiency that was previously cited on 07/30/2024 on Complaint Control # 29-AS-20230714110246. Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

During the visit Sarkis Dovlatyan had to leave the facility due to personal reasons, but stated staff can sign in their place.

Exit interview conducted. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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 12/30/2024 12:52 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/30/2024 at 09:20 AM
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87506(b)(14)

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Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.

This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding along with a written plan to ensure compliance going forward to LPA via email by COB 01/10/2025
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Based on records review, the licensee did not comply with the section cited above as the Department did not receive a LIC 624 for R1’s hospitalization, which posed a potential, health, safety or personal rights risk to residents in care.
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Type B
01/10/2025
Section Cited
CCR87211(a)(1)

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Each licensee shall furnish to the licensing agency such reports...seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include...and disposition of the case. This requirement was not met as evidence by:
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Licensee agreed to review section cited and provide a statement of understanding along with a written plan to ensure compliance going forward to LPA via email by COB 01/10/2025
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Based on records review, the licensee did not comply with the section cited above as the Department did not receive a LIC 624 for R1’s hospitalization, which posed a potential, health, safety or personal rights 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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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