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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 08/05/2025
Date Signed: 08/05/2025 05:11:19 PM

Document Has Been Signed on 08/05/2025 05:11 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/
DIRECTOR:		JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 183CENSUS: 125DATE:
08/05/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Alfonso Lozoya Business ManagerTIME VISIT/
INSPECTION COMPLETED:
05:20 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 Analysts (LPAs) Elena Mallet and Luis De Leon conducted a continuation annual required visit. LPA met with Director Dennis Robeniol and the purpose of the visit was discussed. The facility is licensed to serve elderly residents age 60 and above. It is approved for 136 non-ambulatory residents and 47 bedridden residents, approved for 10 hospice waivers.

REVIEW OF FILES
Resident record review consisted of Admission Agreements, Physicians Report, Needs and Service Plan, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, and Background Clearance. Deficiencies were noted for resident’s for missing updated Needs and Service Plan for R4, TB results missing for R1 and R2, and ambulatory status for R5. Staff records were missing health screening for S1-S5, annual training missing for S2-S4, and first aid certificate missing for S2-S4. Deficiencies were noted on 809D pages.

Observations during facility tour:
  • Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
  • Wall and floors are in good repair. Hallways were clean and free of obstructions.

Report continues on page 809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
Document Has Been Signed on 08/05/2025 05:11 PM - It Cannot Be Edited


Created By: Luis DeLeon On 08/05/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in five (5) out of five (5) staff files did not have a Health Screening form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of staff health screening for S1-S5 via email by POC due date. Licensee shall ensure all staff files contain documentation of health screening records.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three (3) out of five (5) staff files which did not have a verification of annual training, including dementia training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of annual required staff training, including dementia training, via email by POC due date. Licensee shall ensure all staff files providing care contain documentation of the annual training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/05/2025 05:11 PM - It Cannot Be Edited


Created By: Luis DeLeon On 08/05/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three (3) out five (5) staff files which did not have a verification of first aid certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of first aid certification for staff providing care (S2-S4) via email by POC due date. Licensee shall ensure all staff files contain documentation of first aid certification.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two (2) out of five (5) residents' files which did not have Tuberculosis test result in physician's report for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of TB test results via email for R1 and R2 by POC due date. Licensee shall ensure all residents medical assessments show TB test results.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/05/2025 05:11 PM - It Cannot Be Edited


Created By: Luis DeLeon On 08/05/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents files did not have an ambulatory status for R5 on physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of ambulatory status via email for R5 by POC due date. Licensee shall ensure all residents medical assessments show ambulatory status.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents files did not have an updated reappraisal for change of condition for R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
Licensee will provide proof of updated reappraisal via email for R4 by POC due date. Licensee shall ensure all residents reappraisals are completed for change of condition.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/05/2025 05:11 PM - It Cannot Be Edited


Created By: Luis DeLeon On 08/05/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(7)(A)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (A) Provision of emergency power that could include identification of suppliers of backup generators. If a permanently installed generator is used, the plan shall include its location and a description of how it will be used. If a portable generator is used, the manufacturer’s operating instructions shall be followed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above for the disaster plan calls for the use of the onsite backup generator which is currently inoperable and unavailable for use during a disaster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
1
2
3
4
Licensee shall provide an updated disaster plan for power outage during an emergency to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as there is no record of any fire/earthquake/emergency drills being done at the facility since December 19, 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
1
2
3
4
Licensee shall ensure that fire/earthquake/emergency drills are conducted at least quarterly and thereafter. Administrator will conduct fire & earthquake drills, document it and include all staff named during each shift. Submit a copy of the fire/earthquake/emergency drill logs to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
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
VISIT DATE: 08/05/2025
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
  • Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly
  • Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. POC was cleared for previously cited hot water deficiency.
  • Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents.
  • Combo Smoke and carbon monoxide detectors were observed and tested on all rooms. Two (2) fire extinguishers were observed on each floor and were fully charged with the last inspection date on 9/23/2024.
  • There has not been a fire/earthquake/emergency drill conducted since 12/19/2023. A deficiency was noted on page 809D.
  • Front outdoor grounds provide seating and shade and are free from debris and obstructions.
  • The facility offers residents various activities throughout the week. Residents were observed actively engaged on various activities.
  • The medications are centrally stored and locked in the MedTech room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all five (5) residents.
  • LPA conducted interviews with five staff and five residents.
  • LPA reviewed Disaster Emergency Plan and noted deficiency because it calls for the use of inoperable emergency backup generator. The licensee needs to update plan to include instruction for alternate power in the event of power outage. Deficiency noted on page 809D.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D page. Reports LIC 809, LIC 809D and Appeal Rights were discussed and provided to Director Dennis Robeniol.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7