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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 05:23:18 PM


Document Has Been Signed on 05/09/2024 05:23 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
GREATER LA AC/SC, 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: 99DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Janice Shimozawa - Front Desk ReceptionistTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit following the completion of a complaint visit which was conducted on 5/9/2024 and is related to the complaint investigation control #28-AS-20240501153246. LPA met with Janice Shimozawa, Front Desk Receptionist for the facility, and explained the purpose of the visit. Administrator Jina Maleksarkissians arrived shortly thereafter

During the course of the investigation, it had been revealed that police were called to the facility multiple times in the facility's efforts to get homeless individuals to leave the facility premises, however a special incident report (SIR) was never submitted to Community Care Licensing Division (CCLD). There were other serious incidents revealed as well including the resident phone lines being disconnected, copper wiring and other materials were stolen from the facility dining room AC unit as well as the backup power generator for the facility, however incident reports were not submitted for these incidents either to CCLD. These incidents are considered ones that threaten the welfare, safety, or health of the residents, and therefore an SIR should have been submitted to CCLD.

The deficiencies are noted on LIC809D pages per Title 22 Regulations.

Exit interview was held and a copy of this report, along with the LIC809D page and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
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 05:23 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
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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/16/2024
Section Cited
CCR
87211(a)(1)(D)

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(a) Each licensee shall furnish to the licensing agency (...) (1) A written report shall be submitted to the licensing agency (...) within seven days of (...) (D) Any incident which threatens the welfare, safety, or health of a resident.
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The administrator is to ensure that special incident reports are sent to CCLD for all incidents that threaten the welfare, safety, or health of a resident. The administrator is to submit incident reports that detail all of the above incidents to CCLD by the POC due date.
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Based on record review and interview, the LPA determined that the facility did not submit incident reports for events involving police being called to the facility, along with the phone, fax, AC unit, and backup generator being dismantled, which poses a potential safety risk to residents.
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
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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