198602192-5-17-2024-28-AS-LHIS-D5RN5B-20240530100913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602192
Report Date: 05/17/2024
Date Signed: 05/17/2024 05:25:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/20/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231120121606

FACILITY NAME:	SAKURA GARDENS AT LOS ANGELES		FACILITY NUMBER:	198602192
ADMINISTRATOR:	KONISHI, DANIEL		FACILITY TYPE:	740
ADDRESS:	325 S BOYLE AVE		TELEPHONE:	(323) 263-9651
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90033
CAPACITY:	183	CENSUS:	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Jina Maleksarkissians, Executive Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing adequate supervision to residents.
Staff yell at residents.
Staff do not treat residents with respect.
Staff did not safeguard residents' personal belongings.
Staff are not properly dispensing medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was explained to new Executive Director Jina Maleksarkissians.

The investigation consisted of the following: On11/28/23, 2/8/24, and 5/9/24 LPA visited the facility to investigate complaint allegations. On 2/8/24, findings were delivered on 4 allegations. Each visit consisted of physical plant observations, records review, and interviews. Resident file documents were requested and obtained, which included [Medication Administration Records [MARs Sep. 2023- Nov. 2023], Appraisals, Physician's Reports, incident reports] and other relevant documents. Copies of the Neurocognitive Disorder Care Plan of of Operation, Designation of Facility Responsibility, Administrator Certificate, LIC 500 Personnel Report, and resident rosters were obtained. During the course of the investigation, pictures and video evidence was obtained.

***Narrative summary continues next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

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

Allegation: Staff did not safeguard residents' personal belongings. The complaint alleges that staff are instructed to wash resident's clothing and bedding linens together and as a result many of the resident's clothing/personal items are misplaced and/or lost because staff are washing all Memory Care resident's linens together in order to save time. During the course of the investigation, LPA interviewed staff, and family members and information gathered revealed that facility staff ask resident's family members to label the resident's clothing items with permanent marker or a customized name tag label. Family stated that they have noticed their loved one sometimes wearing other resident's clothing, but stated that for the most part the belongings kept at the facility do not have major value. Staff stated the clothing is washed during the NOC shift on days residents are showered. Staff acknowledged that sometimes the resident's clothing is misplaced or lost because the NOC shift staff do not place the belongings in the right resident room, and that the resident's clothing is all washed together. In November 2023, the Memory Care Unit's dryer was not working and staff had to walk to the outside laundry building. Staff stated that due to current laundry assignment protocols the resident's belongings do get mixed up. Staff also reported that some ambulatory residents take other resident's clothing and/ belongings due to cognitive impairment.

Allegation: Staff are not properly dispensing medication as prescribed. It is alleged that the Memory Care Director instructed med-tech staff not to follow physician's orders and dispense extra dosages by increasing the frequency of behavioral medications for at least three (3) residents. Information revealed that resident (R3) had a physician order for Quatiapine "Seroquel" twice a day [8 AM & 8 PM], but the medication was being given 3 times a day as a routine medication per Memory Care Director's instruction, in order to immediately control the resident's behaviors instead of utilizing redirection techniques. The Memory Care Director denied the allegation, and stated that R3 had a previous physician order that was supposed to be dispensed 3 times a day, but the MD changed the order, and stated that it is a routine medication. However, staff all med-tech staff confirmed that R3 was not being given the right dosages, for example a medication of 75 mg (30 min) before breakfast, was being given as 25 mg 3 times a day. Resident (R3's) was supposed to be administered 3 pills of Seroquel at 8 AM and 3 pills at 8 PM, but the Director instructed med-techs to dispense it at 2 AM, 8 AM, 2 PM, and 2 pills at bedtime. According to interviews, the Memory Care Director changed the dosage frequency for multiple residents. Resident (R2's) family member stated that they received a phone call from staff notifying them that Seroquel 25 mg medication ran out, which meant that staff were administering the medication incorrectly and too much. R2 was supposed to be administered Seroquel 25 mg in the AM and 100 mg at bedtime, but they were dispensing Seroquel 25 mg in the AM, 25 mg at noon, and 100 mg at bedtime. Per record review of non-electronic Medication Administration Records (MARs), the findings revealed that staff did not document on MAR records that they were dispensing extra dosages to multiple residents and concealed that multiple residents were being improperly medicated, putting the residents at risk for serious mental and/or physical complications.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. Exit interview was conducted and a copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

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

Allegation: Staff are not providing adequate supervision to residents. The complaint alleges that on November 3, 2023, resident (R1) who resides in the Memory Care Unit left the dining room /activity area after breakfast time and returned to their room to take a nap. It is alleged that the two (2) caregiver staff on duty on 11/3/2023, were sitting in the dining room with other Memory Care residents and failed to check on residents that were in their rooms. At approximately 10:40 AM housekeeper staff (S11) found R1 on the floor of the common shower room. Resident (R1) reported feeling pain in their hip, head, and back. The resident was transported to the hospital where the resident underwent hip surgery because of the injuries sustained after falling. Per resident (R1’s) Needs and Services Plan the resident wanders, is at risk of falling, and requires supervision and assistance when ambulating. Staff are to provide verbal reminders to R1 that they need to use a walker. A total of 11 staff were interviewed. Staff admitted resident (R1’s) injuries occurred because there was a lack of supervision due to staffing shortages i.e., only 2 caregivers in the Memory Care unit because the med-tech/caregiver sometimes must go to the Transitional Memory Care Unit to assist. As a result, many of the residents that are sleeping in their rooms are not always checked every 2 hours per protocols. According to interviews conducted the Memory Care Unit morning shift typically has three (3) staff on the floor, 2 caregiver staff and 1 med-tech staff. Family members interviewed stated they have knowledge that there have been many unwitnessed fall incidents in the Memory Care Unit, and unwitnessed resident to resident aggressive behaviors resulting in injuries. It was also reported that resident (R2) had a private caregiver, and as a result facility staff did not check on the resident as required. In addition, resident (R3) fell during the night shift and was admitted to a hospital with a brain bleed. Memory Care Director stated that caregiver staff are supposed to check on residents every 2 hours. However, the findings indicate that resident (R1) returned to their room after breakfast time at approximately 8:00 AM, and the resident was found injured on the restroom floor until approximately 10:40 AM, which indicates caregiver staff failed to provide adequate care and supervision. Three (3) family members were interviewed, all stated there is not enough supervision of residents. Based on review of records and interviews, there is sufficient evidence to corroborate the allegation.

***Narrative continues next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

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

Allegation: Staff yell at residents. The concerns pertain to the Memory Care Unit staff. It was reported that two (2) Memory Care Unit caregiver staff yell at residents and speak loudly to them, which at times causes residents to get upset and/or have behaviors. According to information obtained, caregiver staff (S5) speaks in an impolite and teasing manner towards cognitively impaired residents. It was also reported that staff (S4) speaks to residents in a very loud voice. It was reported that a resident asked for help and staff mocked the resident in front of everyone in the dining room area. It is alleged that Memory caregiver staff (S5) has been heard speaking in an abnormally loud and aggressive tone of voice to residents. Staff (S4) denied the allegation, and stated that they speak to the residents loudly due to hearing issues. Staff (S5) denied the allegation, yelling across the hallway at residents, and stated that they speak to them in a loud tone because many residents are hard of hearing. According to both staff identified as yelling at residents, they both have high deeper voices that may come across as aggressive. However, a total of 11 staff were interviewed, eight (8) staff confirmed the allegation by stating that staff (S5) talks to residents in an impatient, abrupt tone of voice, rude, inappropriate manner, easily gets irritated by resident's requests, has a bad attitude with the residents, and says "you're crazy" to the Memory Care residents. The findings indicate that the Memory Care Director has addressed staff (S5's) conduct, but their was no disciplinary action, therefore, the behavior continued until recently when Community Care Licensing began investigating the complaint.

Allegation: Staff do not treat residents with respect. It was reported that Memory Care staff sometimes speak to the residents in a disrespectful manner and laugh at residents because staff know that due to their cognitive impairment they cannot discern that they are being made fun of. Information gathered revealed that one resident carries their pillow around and staff laugh, some caregivers ask residents for massages for fun, some staff fail to refer to the residents in a culturally appropriate manner i.e., using "San" after addressing them by their first name; instead address the residents by saying "mama or papa". The findings indicate staff (S5) often verbally provokes residents, has been observed sitting in resident walkers, and inappropriately handling/lifting/pulling up a resident while toileting in the bathroom. Staff (S5) pulled the back of the resident's shirt to lift the resident, which is not an appropriate way of handling an elderly non-ambulatory resident. Seven (7) out of 11 staff acknowledged they have observed or heard other staff address and treat the residents in a disrespectful manner. Video and two (2) pictures were obtained, one depicted staff (S10) sitting on a resident's walker being given a upper back massage by a resident, and another picture depicted a resident eating a meal with a cloth napkin on their face, while the resident was holding a cup of juice. The video sound captured staff laughing.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Administrator agrees to: 1. Submit a written plan by tomorrow how the deficiency will be corrected. 2. Conduct caregiver staff training on regulation 87466, Memory Care care and supervision protocols, and staff communication regarding resident incidents and/or changes in condition. 3. Submit proof that staff were trained by 5/22/2024.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on records review and interviews conducted, staff failed to provide provide adequate care and supervision, resulting in injuries that occurred on 11/3/23 to R1 that required hospitalization and hip surgery. This is an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Type B 05/22/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator agreed to conduct Personal Rights training/sign-in sheets and will submit written proof of how the facility will address the issues. Submit by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the findings revealed that staff (S5) yells at residents, is impatient, and mocks Memory Care residents, and multiple residents are not treated with respect and dignity due to S5 & S10's behavior, this poses a potential health and safety risk.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/18/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all .... requirements are met: Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Administrator agreed to submit proof of staff in-service training in facility medication administration procedures, and "CCLD Medication Guide". Administrator shall ensure that medication administration procedures are being evaluated routinely and adhered to by all med-tech staff.
	8 9 10 11 12 13 14	Based on records review and interviews, Memory Care Director instructed med-tech staff to increase the frequency of medication administration of behavioral medication Quetiapine (Seroquel) to residents (R2 & R3) without a physician order; which poses an immediate health and safety hazard to the residents.	8 9 10 11 12 13 14	Submit proof of staff training by 5/22/24. ***NOTE: The facility does not have a Electronic Medication Administration Record (eMAR) system in place. Administrator was advised to look into EMAR software.
Type B 05/22/2024 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agreed to: 1. Develop a written Plan of Correction (POC) in which a system is created that safeguards resident’s personal items after laundering the clothing and bedding linens. 2. Conduct/submit proof of staff training
	8 9 10 11 12 13 14	Based on interviews conducted, residents clothing and bedding linens are being misplaced or lost because in order to save time Memory Care staff are washing residents clothing/bedding items together, and sometimes items are not returned after being laundered, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/20/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231120121606

FACILITY NAME:	SAKURA GARDENS AT LOS ANGELES		FACILITY NUMBER:	198602192
ADMINISTRATOR:	KONISHI, DANIEL		FACILITY TYPE:	740
ADDRESS:	325 S BOYLE AVE		TELEPHONE:	(323) 263-9651
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90033
CAPACITY:	183	CENSUS:	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Jina Maleksarkissians, Executive Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not inform resident's authorized representative of incident.
Staff did not provide resident with food or water.
Staff are not following reporting requirements.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

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

Allegation: Staff did not inform resident's authorized representative of incident. According to information received resident (R1) sustained two falls in 2023. It is alleged that the fall that occurred on September 20, 2023, at approximately 12:45 AM was not reported to R1’s authorized representative. Per record review, the authorized representative was notified shortly after the fall. Family (F1) resident (R1’s) authorized representative stated they do not remember whether staff called them after the September 20, 2023, incident, but acknowledged receiving notification of the fall incident that occurred on 11/3/2023. Most of the staff interviewed stated it is protocol to call the resident’s authorized representative and their doctor after incidents. Staff interviewed denied the allegation, and per record review the findings indicate that the facility documented they called responsible parties, 911 emergency, doctor, and submitted incident reports to Community Care Licensing as required. There is insufficient evidence to corroborate the allegation.

Allegation: Staff did not provide resident with food or water. It is alleged that there have been multiple incidents in which Memory Care staff failed to serve resident (R2) breakfast or lunch meals because the resident is primarily in their room and sleeps in during the morning hours. According to information obtained, if the resident is sleeping, they do not call the resident to the dining room to eat and have forgotten to feed or provide hydration to the resident and when the Memory Care Director was informed that R2 had not been fed lunch at approximately 2 PM, the Director responded by saying that R2 has a private caregiver. Eight (8) out of 11 staff denied the allegation and stated that R2 liked to eat their breakfast between 8 AM- 9 AM, therefore, they ate their lunch later as well. All staff stated that R2 had a good appetite and always ate their 3 meals but refused to eat with other residents in the dining room. Staff reported that when residents are in their rooms, they are supposed to check on them every 2 hours and leave water on the commode side table. Resident (R2's) family member stated that the resident slept a lot, water was always observed in the resident's room, and the resident ate vert fast and finished their food. Family did not have concerns regarding the allegation but did state that they were not present during most mealtimes. There is insufficient evidence to prove the allegation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 28-AS-20231120121606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2024

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

Allegation: Staff are not following reporting requirements. It is alleged that staff are not reporting all incidents to family members and Community Care Licensing Division (CCLD) because the Memory Care Director instructed staff to only report when there is visual blood. According to information obtained, there were 2 incidents involving resident altercations that were not reported to responsible parties, and there was a fall incident that occurred during the NOC shift, in which 911 was not called, nor was it reported to appropriate parties. Staff interviewed stated that it is the med-tech’s responsibility to report incidents to family, physicians, and write a report that is then provided the Memory Care Director. Most of the caregiver staff and med-techs stated they do not know whether there is an issue with reporting appropriate parties and/or agencies. A total of 3 family members were interviewed, one stated they do not have knowledge of whether staff are not following reporting requirements, another stated that they receive immediate notification if there is an incident, and the 3^rd family member reported that their loved one was a victim of financial fraud, but that staff have not notified them of the suspected abuse. There is insufficient evidence to corroborate the allegation, because CCLD did receive via fax the majority of the aforementioned incidents.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Jina Maleksarkissians.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9