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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 06/28/2024
Date Signed: 06/28/2024 03:58:54 PM


Document Has Been Signed on 06/28/2024 03:58 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
CCLD Regional Office, 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: 130DATE:
06/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Jina MaleksarkissianTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff Janice Shimozawa and the purpose of the visit was discussed. Administrator Jina Maleksarkissian arrived shortly after.

LPA completed the following domains:
1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. LPA observed and reviewed the infection control plan
2. Physical Plant/Environmental Safety: LPA toured the facility inside and out to ensure there are no health and safety hazards. The facility consists of three 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. Activity Hall that consists of an auditorium, activity room and area for storage. LPA inspected rooms #111, #113, #1007, #1001, #1003, #1002, #523, #415, and #207 they all have required grab bar and non-skid mat in the bathrooms. Each residents' bathrooms are clean, sanitary and in a operable condition. LPA tested hot water temperatures and they were between 105 and 120 degrees F. which are within Title 22 regulation. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well. Facility also has a fire panel inspected regularly. Each residents room have the required furniture, bedding and sufficient lighting and closet space. The facility have a telephone services in the premises.
3.Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does have a Dementia Care Plan. A hospice waiver is approved for (10) residents. A fire clearance for (183) capacity of which (136) may be non-ambulatory and (43) bedridden . Liability Insurance reviewed and matches Licensing requirements.

Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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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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: 06/28/2024
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4. Staffing: completed initial visit

5. Personnel Record/Training's : The Administrator is Administrator Jina Maleksarkissian and her administrator certificate is currently pending review for renewal. All the facility staff have criminal background clearance and associated with the facility and the required training. Nine (9) staff files were reviewed.
6. Residents Records-Incident Reports: A total of ten (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.
7. Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance and reception area.
8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar is available and the facility has a full time activity director in place.
9. Food Services: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on residents' file. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly.
10. Incidental Medical and Dental Services: Ten (10) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.
11. Disaster Preparedness: The facility has a Emergency and Disaster Plan created by the facility. The facility also has two alternative temporary shelter locations listed. Technical Violation will be provided due to further information needed on the emergency disaster plan.
12. Resident with Special Health Needs: Five (5) residents are receiving home health services. There are no residents receiving hospice care. No postural support residents currently reside in the facility. No half bed or full bed rails were observed in resident rooms. Individual Service Plans and Appraisals are on File. No residents have prohibited health condition.

No deficiencies were observed during the annual inspection. Exit Interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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