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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 06/21/2023
Date Signed: 06/21/2023 06:59:15 PM


Document Has Been Signed on 06/21/2023 06:59 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:SARKIS DOVLATYANFACILITY TYPE:
740
ADDRESS:15149 SYLVAN STREETTELEPHONE:
(818) 666-1665
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:6CENSUS: 6DATE:
06/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Sarkis Dovlatyan - Administrator TIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Brian Balisi and Zabel Chochian conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20230411112334). LPAs met with Sarkis Dovlatyan. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

During the complaint investigation, interviews conducted reflected that all matters related to the operation of the facility such as payment for services, hospice care, and any matters related to the well-being of the residents are communicated with an individual named Anna Hakobyan. Interview with Administrator revealed that they have been business partners for approximately 10 years, but Administrator indicated they receive payments from all residents and denied any knowledge of any residents paying or being in contact with Anna. Administrator continued to state families may be in contact with Anna for hospice or home health services. LPAs discussed with administrator that Anna Hakobyan was excluded by the Department and should not have any involvement with the day-to-day operations of the facility. A copy of the accusation was also provided to the administrator during today’s visit.

In addition, during today’s visit, LPAs conducted a physical plant tour at approximately 9:45am and observed five (5) out of five (5) residents with full bed rails. Resident records review at approximately 1pm – 2pm, revealed that the facility does not maintain accurate resident records. Administrator and LPA reviewed five (5) resident hospice records and did not find any order for the full rails. Five (5) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. No staff records on site to review. During the visit Administrator revealed to LPAs their Administrators certificate is expired.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 06/21/2023 06:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2023
Section Cited
CCR
87608(a)(5)(B)

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Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement was not met as evidenced by:
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Licensee agreed to remove all full bed rails or submit proof of hosice care plans to LPA via email by EOD 06/22/2023.
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Based on observervation the LIcensee did not comply with this regulation as LPAs observed full bed rails in (5) out of (6) clients in care. This poses an immediate health and safety risk to the residents in care.
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Type A
06/22/2023
Section Cited
HSC1569.58

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a) The department may prohibit any person from being a licensee...,any employee, prospective employee, or person who is not a client and who has done any of the following: This requriement was not met as evidenced by:
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Licensee has been informed and provided a copy of the Decision and order and understans that the individual cannot have any form contact with clients at any facility licensed by the department. Licensee will also submit a statment of understanding of section cited to LPA by EOD 06/22/2023.
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Based on interviews conducted interviews conducted reflected that all matters related to the operation of the facility such as payment for services, hospice care, and any matters related to the well-being of the residents are communicated with an individual named Anna Hakobyan
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 06/21/2023 06:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87412(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement was not met as evidenced by:
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Licensee agreed to maintain full staff files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/30/2023.
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Based on interviews and records review, LPAs did not observe any staff records on site to review. This poses a potential health and safety risk to the residents in care.
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Type B
06/30/2023
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 and submit to LPA via email by EOD 06/30/2023.
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Based on records review Five (5) out of five (5) resident records reviewed did not have a centrally stored medication record, complete resident appraisal, preplacement, needs and services plan, and complete hospice records. 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/21/2023 06:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 197608986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87633(b)

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(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement was not met as evidenced by:
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Licensee agreed to maintain full hospice care plan in the facility. LIcensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/30/2023.
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Based on interviews and records review the licensee did not comply with the section cited as LPAs reviewed revealed five (5) resident hospice records and did not find any order for the full rails. This poses a potential health and safety risk for residents in care.
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Type B
06/30/2023
Section Cited
CCR87405(a)

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All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by:
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Licensee agreed to submit request for change of Administrator along with the supporting documents to LPA by EOD 06/30/2023.
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Based on interviews conducted Licensee did not comply with the section cited as Licensee revealed to LPAs their Adminitrators certificate is expired. 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4