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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 01/03/2023
Date Signed: 01/03/2023 10:44:53 AM


Document Has Been Signed on 01/03/2023 10:44 AM - 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:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 6DATE:
01/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sarkis Dovlatyan - Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Other visit at the facility. At approximately 9am, LPA was greeted by staff and explained the reason for the visit. Upon entering facility LPA was then met by Administrator Sarkis Dovlatyan.

At approximately 9:05am, LPA toured facility with Administrator and spoke with Admin regarding recent staffing concerns. LPA also spoke with the (2) staff on duty. LPA reminded Administrator to submit paperwork for back up Administrator and provide updated LIC 500 to LPA by end of day. Administrator stated they will be overseeing facility at this time and will ensure there will be sufficient staffing until new management takes over. Administrator also indicated they have been in constant communication with new management.

No immediate health and safety concerns were observed during today's inspection.

Exit interview conducted report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
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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