Facility Evaluation Report, 12/06/2021 — Age Well Assisted Living Facility, Van Nuys CA

Licensing Program Analysts (LPAs) KaSandra Lopez and Martha Guzman-Chavez conducted an unannounced Case Management - Deficiencies report due to deficiencies observed during the complaint investigation of complaint control #29-AS-20211201090238 beginning at 11:05 AM. At 11:33 AM Dinah Pasco who was identified as the Administrator by the caregiver, was contacted and the LPAs spoke with her and advised her of the reason for today's inspection. The LPAs met with Dinah Pasco at 12:05 PM at the facility. At 12:32 PM the LPAs spoke with Licensee Representative Sarkis Dovlatyan on the telephone and explained to him the reason for the inspection also. Licensee Representative confirmed Dinah Pasco was the new Administrator and stated the paper for the change had been submitted.

During the complaint investigation, it was observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not associated to the facility. Interviews with S1, S2, and S3 revealed each staff have worked at the facility for more than five days. Therefore, civil penalties will be assessed in the amount of $500 ($100 a day x 5 days) each for S1, S2, and S3.

Resident record review was conducted for three of the five residents beginning at 1:52 PM. Record review revealed, Resident #1 (R1) did not have a completed facility file, including signed admission agreement, medical assessment, emergency identification, signed personal rights, or appraisal on file. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) was missing the rate for basic services on their signed admission and did not have a medical assessment on file, and Resident #3 (R3) did not have a signed admission agreement on file.

At 5:57 PM, Licensee Representative Sarkis Dovlatyan was contacted via telephone to go over the report and to discuss the following. On approximately 04/09/2015, Corporation Age Well Assisted Living, Inc. listed Sarkis Dovlatyan as 100% owner of the corporation. Report continued on LIC 809-C.