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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:10:08 PM

Document Has Been Signed on 02/13/2025 03:10 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAKURA GARDENS AT LOS ANGELESFACILITY NUMBER:
198602192
ADMINISTRATOR/
DIRECTOR:		JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 183CENSUS: DATE:
02/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Dennis Robeniol, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced case management visit due to deficiencies noted during a complaint visit conducted on 11/26/24. LPA met with Dennis Robeniol, Executive Director and explained reason for the visit.

During complaint investigation, LPA Cota reviewed Medication Administration Record (MAR) logs for Resident 1 (R1) and Resident 2 (R2). LPA Cota noted, R2's MAR logs for September, October and November 2024 were incomplete. MAR logs reviewed were missing multiple initials. The MAR logs were missing initials for medication required to be administered daily, once or several times a day.

Deficiency cited on LIC-809D per Title 22 Regulations.

Exit interview conducted with Dennis Robeniol, Executive Director and a copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/13/2025 03:10 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/13/2025 at 11:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
03/13/2025
Section Cited
CCR
87506(a)

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Resident Records 87506(a) Licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ... readily available to facility staff and to licensing ... This requirement is not met as evidenced by:

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Director will provide in-service training with staff pertaining to medication administration and proper documentation. Director will review job duties with med-techs and their supervisory staff and provide proof of training and attendance roster to LPA via email by POC due date.

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Based on file and record review of R2's MAR logs were incomplete. MAR logs were missing multiple initials for medication required to be administered daily, once or several times a day, which poses a potential 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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
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