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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602192
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:07:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
11/18/2024 and conducted by Evaluator Mayra Cota
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241118081448
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: 126DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dennis Robeniol, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not meet resident’s needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA met with Dennis Robeniol, Execitive Director and discussed the purpose of the visit.

The investigation consisted of the following: LPA toured the facility, reviewed file and records of Resident #1 (R1) and obtained copies of the following documents: Face Sheet, Needs and Service Plan, Resident Assessment, Admissions Agreement, Physician’s Report, Medication Administration Record (MAR) for November 2024, Admission Orders (medication), photo of purchase receipt for glucometer and test strips, Physician Orders for Life-Sustaining Treatment (POLST), Unusual Incident Report (11/14/24) and Admission Record and Order Summary Report from convalescent hospital. Staff also provided staff and resident rosters. LPA conducted interviews with residents 1-9 (R1-R9), staff 1-4 (S1-S4), and convalescent hospital staff (CS).
***Continues on LIC 9909-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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-20241118081448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 02/13/2025
NARRATIVE
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Allegation: Staff did not meet resident’s needs.

Regarding allegation, “Staff did not meet resident’s needs,” it is alleged, staff did not provide resident with insulin and diabetic supplies to check sugar. During the investigation, interview with R1 indicates, facility staff did not have their insulin after being transferred from convalescent hospital. R1 reported to staff they were feeling sick and was transported to hospital via ambulance. Review of Special Incident Report dated 11/14/2024, indicates, R1 was assessed by paramedics with Hypoglycemia being high, at 561. Interviews with S1 indicate, facility received the insulin, however, it was not administered. Interview with S2 also confirms, R1 did not receive insulin dose at the facility. Additionally, interviews with DS indicate, R1 was transferred to facility from convalescent home with all their medication, including their insulin. Review of medication inventory lists from facility and convalescent hospital further indicate insulin was included in the medication R1 took to the facility during their transfer from convalescent hospital.

Based on LPA’s observations, file and record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation has been determined to be SUBSTANTIATED. Deficiency cited on LIC 9909-D.

Exit interview was conducted with Dennis Robeniol. A copy of the report and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
11/18/2024 and conducted by Evaluator Mayra Cota
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241118081448

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: DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dennis Robeniol, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Allegation: Staff Ignored resident’s requests.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA met with Dennis Robeniol, Executive Director and discussed the purpose of the visit.

The investigation consisted of the following: LPA toured the facility, reviewed file and records of Resident #1 (R1) and obtained copies of the following documents: Face Sheet, Needs and Service Plan, Resident Assessment, Admissions Agreement, Physician’s Report, Medication Administration Record (MAR) for November 2024, Admission Orders (medication), photo of purchase receipt for glucometer and test strips, Physician Orders for Life-Sustaining Treatment (POLST), Unusual Incident Report (11/14/24) and Admission Record and Order Summary Report from convalescent hospital. Staff also provided staff and resident rosters. LPA conducted interviews with residents 1-9 (R1-R9), staff 1-4 (S1-S4), and convalescent hospital staff (CS).
***Continues on 9909C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20241118081448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 02/13/2025
NARRATIVE
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It is alleged, staff declined to listen to resident and only listened when they asked staff to call the ambulance when they did not feel well. During the investigation, eight out of nine residents interviewed stated, staff are helpful, and they meet their needs in a timely manner. Residents stated staff are nice and they have not experienced any problems during their time at the facility. Staff interviewed stated, staff ensure care and supervision of residents is met by conducting scheduled status checks. There is Life Alert necklace system in place for all residents to ensure they have a way to communicate with staff at any time. During tour of the facility, LPA observed multiple staff providing care and supervision to residents in their rooms and during daily activities throughout the facility.

Based on LPA observation, file and record review, and interviews conducted, the allegation listed above could not be corroborated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.


An exit interview conducted with Dennis Robeniol, Executive Director. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241118081448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
876289(b)(1)
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Diabetes 87628(b)(1): (b) In addition to Section 87611, General Requirements by Allowable Health Conditions, the licensee shall ... : (1) Assisting residents with self-administered medication as specified in Section 87465, Incidental Medical ... Services. This requirement is not met as evidenced by:
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Licensee will email LPA proof of scheduled training with staff which will address policies and procedures regarding new admissions to the facility. Upon completing training, licensee will also send LPA training agenda and attendance rosters.
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Based on observation, file and record review, and interviews conducted, Licensee did not provide resident with insulin and diabetic supplies which poses an immediate health, safety, or personal rights risk to 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5