<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 07/19/2021
Date Signed: 07/19/2021 04:03:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAKURA GARDENS AT LOS ANGELESFACILITY NUMBER:
198602192
ADMINISTRATOR:KONISHI, DANIELFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:177CENSUS: 123DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Daniel KonishiTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Executive Director Daniel Konishi and the purpose of today’s visit was explained.

There are currently (123) residents in the facility. The facility is licensed to serve elderly residents age 60 and over, (177) total capacity all non-ambulatory. (23) of the (177) to reside in the memory care wing of the facility.

LPA and Executive Director Daniel Konishi toured the facility's physical plant inside and outside to ensure there are no health and safety hazards. The facility consists of two separate buildings: Retirement building is a 5 story building that consists of 127 units each with private restroom, lobby area, administrative offices, public restrooms, library, TV Room, Activity room, laundry room, Health & Wellness room, commercial kitchen and dining room.

Memory Care Wing consists of 13 rooms, 5 restrooms, gated courtyard, activity room/ dining room, lobby, laundry room, medication room and administrative office.

LPA toured the common areas, resident rooms which include private restrooms, kitchen, dining area, public restrooms and outside areas. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and non-skid mats or strips were properly in place. Water temperature was measured in a total of 13 resident rooms and temperatures ranged from 112 to 120.2 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 07/19/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed that required documents are posted as mandated. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. Medications are properly stored, locked and inaccessible to clients.

LPA toured the kitchen which appeared clean and the appliances and fixtures functional. Kitchen observed to be within Title 22 regulations. The kitchen was observed for the ability to prepare and serve food. There was enough supply of perishable foods and nonperishable foods. Perishable food was stored in covered containers at the appropriate temperature. All cleaning solutions, and hazardous items were securely locked and inaccessible to residents. The facility has central air and heating accommodations. The facility was observed to be in good repair.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in facility storage. LPA observed hand sanitizer stations throughout the facility. LPA observed facility staff wearing masks, 2 resident bedroom located in the memory care building will be converted to an isolation rooms (when needed) and required postings will be placed outside of the rooms. LPA observed the required postings throughout the facility. The residents temperature's are checked and logged twice a day in the AM and PM. Facility has an adequate amount of PPE and facility has enough PPE for 30 days.

The air temperature was cool and comfortable throughout the facility at the time of visit. There are no security bars or weapons on the premises. Koi Ponds at facility are surrounded by a metal gate.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Executive Director Daniel Konishi and copy of report provided.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2