197608986-12-28-2022-29-AS-JAPL-CMXUB6-20230110142550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608986
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:20:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2022 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220516152826

FACILITY NAME:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR:	SARKIS DOVLATYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 6	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Villalyn Agustin, Staff		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Facility does not have a desginated subsititute administrator.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Christine Yee, conducted a subsequent complaint visit to conduct further investigations and to deliver the findings of the above allegation. LPA Yee met with Villalyn Agustin, staff and the reason for today's visit was explained.

On 5/23/22, LPA Brian Balisi conducted an intial complaint visit. During the initial complaint visit, LPA Balisi interviewed staff, residents, reviewed and obtained copies of pertinent documents relevant to the investigation and determined that further investigation was required.

On today's visit, LPA Yee conducted face to face interviews with Staff #1, Staff #2,

continued on LIC9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220516152826

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/28/2022

NARRATIVE

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Sarkis Dovlatyan, former Licensee, Residents and reviewed facility documents. Per information received during the investigation, the last known Administrator was Dinah Pasco and she resigned on April 10, 2022, per the resignation letter observed in her facility file. Ms. Pasco was also disassociated from the facility on 5/1/22 per Department records. Department records show that administrator documents were submitted for Katchik Danielian as designated backup administrator on June 1, 2022. However, the documents were incomplete and the appropriate criminal record clearances were not obtained to qualify Katchik Danielian as a backup administrator. Per Staff, they report to a Anna Hakobyan and John Santos via telephone if there are any issues at the facility issues. They are not present at the facility. Per interview conducted with Sarkis Dovlatyan, former Licensee who resides next door to the facility, he is always around the facility but he is the property owner and has had no involvement with the daily operations of the facility since 8/1/2022 and does not provide any administrative oversight other than maintenance services.

Based on information obtained during the investigation and observed on today's visit, the facility does not have any qualified administrator or backup administrator on the premises to provide administrative oversight. Therefore, the above allegation is SUBSTANTIATED.

Deficiencies are being cited under Title 22 Division 6 Chapter 8 of the California Code of Regulations.

Exit interview was conducted with Villalyn Agustin, Appeals Rights were discussed and a copy of the report was given.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220516152826

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 01/06/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405(a) Administrator Qualifications and duties: (a)All facilities shall have a qualified and currently certified administrator....When the administrator is not in the facility, there shall be coverage by a	1 2 3 4 5 6 7	The licensee will submit a plan of action as to how the facility will come into complance by 12/29/22 and submit Administrator documents to designate a qualified person as facility administrator and another
	8 9 10 11 12 13 14	designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement was not met and poses an immediate danger to the residents in care	8 9 10 11 12 13 14	person as backup administrator by 1/6/23
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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