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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:22:53 PM


Document Has Been Signed on 05/09/2024 01:22 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SAKURA GARDENS AT LOS ANGELESFACILITY NUMBER:
198602192
ADMINISTRATOR:JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:183CENSUS: 131DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Administrator Maleksarkissians, JinaTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Reyes generated this Case Management - Deficiencies report in conjunction with complaint control #28-AS-20231120121606 pertaining to observations made during the physical plant inspection of the Memory Care Unit. The purpose of the report was explained to Administrator Maleksarkissians,Jina.


At 11:18 AM, during the tour of physical plant inspection of the Memory Care Unit LPA Reyes witnessed in resident's #1 (R1) on the window seal a bottle of opened Listerine Antiseptic Mouthwash. LPA took photos of the open bottle of Listerine Antiseptic Mouthwash on the window seal before it was removed by staff #1 (S1).

LPA interviewed S1 and observed S1 remove the bottle of Listerine Antiseptic Mouthwash and centrally store and lock bottle.

Upon LPA's record review of R1 it was observed that R1's Physician Report was dated 2/22/2021. Resident (R1) resides in the Memory Care Unit and is diagnosed with Alzheimer's/Dementia. Per title 22 California Code of Regulation 87705 Care of Persons with Dementia 87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


Based on observation, a citation is being issued. See LIC 809D.

An exit interview was conducted and a copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 01:22 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
87705(g)(1)

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Care of Persons with Dementia (g) residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1)Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items.
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Executive Director agreed to submit proof of staff in-service training and a written plan of correction stating how the deficiency was corrected that includes facility protocols.
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Based on LPA's observation during the tour of the physcial plant at 11:18am in room number 1010 an open bottle of Listerine Antiseptic Mouthwash on the window seal was observered. The poses an immediate health/safety risk to the residents in care.
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Type B
05/16/2024
Section Cited
CCR87705(c)(5)

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Executive Director agreed to submit a written plan of correction and proof of staff training on regulation 87705.
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Based on LPA's record review of R1's file the Physician's Report dated 02/02/2021 it was observed that the resident did not have an annual medical assesment, as required for Dementia residents; which 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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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