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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602192
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:51:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240129142303
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:183CENSUS: 134DATE:
02/07/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Tomoko Hino - Sales Marketing DirectorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Resident sustained multiple falls due to staff neglect
Staff did not follow protocol regarding resident falling
Staff administered resident medications not on medication list
Facility staff did not report resident's fall to the proper agencies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Tomoko Hino and explained the reason for the visit. Whitney Blake Regional Vice President of Operations and Sale for North Star was notified of the reason of the visit via phone.

The investigation consisted of the following: LPA requested a copy of staff and resident roster. Interviewed administrator, 5 staff, 8 residents, reviewed resident’s #1(R1) file, staff provided a copy of R1’s file and incident reports for incidents on 1/15/24 and 1/24/24. Interview hospice services over the phone.

The investigation revealed the following: Regarding allegation: Resident sustained multiple falls due to staff neglect. It is alleged R1 has a history of falls and fell on 1/15/24 and 1/24/24. Interviews with staff revealed R1 resided at the assisted living prior to moving to their transitional memory care unit. While living at the assisted living R1 had sustained one fall only. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20240129142303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 02/07/2024
NARRATIVE
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After the fall R1 obtained rehabilitation at an outside facility and returned to the transitional memory care in November of 2023. R1 had two falls one on 1/15 and one on 1/24/24. Document review revealed the following: Physician’s report dated 9/6/23 notes R1 is ambulatory. Resident assessment dated 12/4/23 notes special concern – care level description fall concern. Needs and Services Plan dated 11/21/23 notes “resident will ambulate with walker”, however it does not note that the resident is at risk of falls. Incident report dated 2/2/24 to report incident on 1/15/24 notes R1 “glided on the floor hitting the knees” and does not note information on action taken or planned to prevent future falls. Incident report dated 2/2/24 to report incident on 1/24/24 notes care staff found R1 siting on the floor and was picked up. No action taken or follow ups are noted. Hospice plan of care dated 2/7/24 notes R1 has had repeated falls. Hospice plan was created on 12/13/23. One of the goals created was to prevent falls and minimize injury. Facility staff failed to follow Hospice care plan to prevent falls and to update or provide a plan of care to be followed by staff to prevent falls for R1.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff did not follow protocol regarding resident falling and Facility staff did not report resident's fall to the proper agencies. It is alleged staff did not follow protocol of assessing the resident, calling hospice, and picked up resident and staff decided not to report the fall to reporting parties. Interviews with residents revealed 6 out of 8 residents stated staff are helpful and will call 911 for them in case of a fall. 2 out of residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed that staff are to evaluate the resident, notify supervisor, call 911 or hospice services, notify family, and notify community care licensing (CCLD)/ Local Ombudsman (LTCO). Per Memory Care Director, for residents under hospice they are to call hospice agency and speak with a nurse who will provide instructions for care of a resident that has fallen. Interview with hospice agency revealed that facility did not notify them of the falls R1 had on 1/15/24 and 1/24/24 and only came to know of the incidents through a third party during the visits. Incident occurred on 1/15/24 does not note any action taken by the facility. Incident occurred on 1/24/24 notes “sitter said not to call 911 and was assisted to get up”. Incident reports for incidents occurred on 1/15/24 and 1/24/24 were submitted to the department on 2/2/24. Facility failed to follow their own protocol to call hospice services for R1 and obtain instructions of care for R1 and facility failed to report to CCLD within 7 days. (CONTINUED ON LIC 9099C)
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240129142303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 02/07/2024
NARRATIVE
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Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff administered resident medications not on medication list. It is alleged facility med tech provided medication to R1 that has not been prescribed. Interviews conducted revealed 6 out of 8 residents interviewed either managed their own medication or had no issues with medication provided. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed only Med-Techs provide medication to residents and before providing medication staff review the medication sheet and ensure they are providing the correct medication before giving it to the resident. Documents review revealed Facility’s medication administrator record for January 2024 notes R1 was provided acetaminophen 500mg, noted on a posted note dated 1/24/24 attached to medication administration record which notes “give R1 acetaminophen 500, 1 table at 10:25am” with staff initials. R1 hospice current treatment/medication/DME list does not list Tylenol 500 mg as a prescribed medication for pain between 12/13/23 – 1/26/24.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Tomoko Hino and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240129142303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents...: (a)...residents...: (4) To care, supervision,... meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...
This requirement is not met as evidence by:
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Licensee will provide training to memory care staff regarding updating needs and care plan, notifying staff providing care of updates, and following care plan for residents and will provide a copy of training with subject, duration of training, and signing log to the department by POC due date 2/8/24.
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Based on interviews conducted and documents review licensee did not ensure that R1 had a plan of care for fall risk after hospice documented which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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Type A
02/08/2024
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable...: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:
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Administrator will provide staff training on Medicaiton safety, and ensuring correct medication to memory care staff and will provide a copy of training with subject, duration of training, and signing log to the department by POC due date 2/8/24.
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Based on documents review and interviews licensee failed to ensure that R1 received medication as prescribed and was given acetaminophen 500mg on 1/24/24 which poses an immediate risk to the health, safety, or personal rights of the persons 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240129142303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2024
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons with Dementia
(c) Licensees...shall be responsible...: (4) ...direct care staff to support each resident’s physical, social, emotional, safety and health care needs...
This requirement is not met as evidence by:
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Licensee will provide provide training on protocols and guidelines for care of residents after a fall and will submit a copy of training with subject, duration of training, and signing log to the department by POC due date 2/14/24.
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Based on documents review and interviews licensee did not ensure to follow protocol for R1 after falls obtained on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons in care.
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Type B
02/14/2024
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements a) Each licensee shall ..: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
This requirement is not met as evidence by:
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Licensee will provide training to reporting staff on time, description, action taken, follow up information on incident reports and will submit a copy of training with subject, duration of training, and signing log to the department by POC due date 2/14/24.
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Based on documents review and interviews conducted licensee failed to inform CCLD and physician (hospice agency) regarding falls ocurred on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5