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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:12:27 PM


Document Has Been Signed on 07/29/2022 02:12 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:KONISHI, DANIELFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:177CENSUS: 125DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Daniel Konishi, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Ya-Ting Yang conducted the annual inspection with the focus of the Infection Control domain. LPA met with Administrator Daniel Konishi and explained the purpose of the visit. The facility is approved for 177 non-ambulatory residents ages 60 and above. There is a hospice waiver for 10 residents.

LPAs toured the campus which consists of 2 buildings, one for Assisted Living residents with 5 floors and another with a single story Memory Care unit. There are currently 102 residents residing in the Assisted Living building and 23 residents in the Memory Care unit. LPAs randomly selected a total of 14 rooms to inspect: Memory Care unit rooms #1003, #1005, #1007, and #1015; Assisted Living rooms #102, #116, #207, #220, #307, #316, #403, #407, #508, and #511. The rooms consist of the required furniture and smoke/carbon monoxide detectors were tested for those rooms. Restrooms were inspected and all appear clean with paper towel dispensers and hand soap. Per Administrator, the housekeepers clean daily and disinfect high touched surfaces. LPAs observed hand sanitizers available for use on each floor. There were at least 30 days of PPE supplies such as N95 masks, gloves, and gowns. There were sufficient food supplies of 2 day perishable and a week of non-perishable items. Cleaning supplies are stored and locked in the housekeeping storage room. The facility continues to screen and take the temperature of all visitors and staff upon arrival. LPAs observed all staff members and visitors wearing face masks at the facility.
LPAs reviewed the medication log for 12 residents and the medications are being administered as prescribed.
Per the Administrator, he is still following the mitigation plan and performing weekly covid-19 testing for those who are not vaccinated or fully vaccinated.

No deficiencies were issued during today's visit. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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