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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 07/10/2023
Date Signed: 07/10/2023 03:45:50 PM


Document Has Been Signed on 07/10/2023 03:45 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:KONISHI, DANIELFACILITY TYPE:
740
ADDRESS:325 S BOYLE AVETELEPHONE:
(323) 263-9651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:177CENSUS: 131DATE:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Daniel Konishi - Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Daniel Konishi (Executive Director), the reason for the visit was explained upon arrival. There are currently (131) residents in the facility. The facility is licensed to serve 177 non-ambulatory elderly residents ages 60 and over. There is a hospice waiver for 10 residents, and 23 of the 177 to reside in the memory care wing of the facility.

The facility consists of two 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.

LPA attempted to utilize the Compliance and Regulatory Enforcement (CARE) tools for the visit today, however, due to a system glitch LPA was unable to utilize Care Tools, during todays visit LPA and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are a total of 127 rooms in the retirement building which each have room has its own restroom and 13 rooms in the memory care wing each with 6 shared restrooms. LPA toured the common areas, 14 resident rooms, kitchen, dining area, public restrooms and outside areas. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for
(Continued on 809-C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 07/10/2023
NARRATIVE
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comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied. Water temperature was measured in a total of 14 resident rooms and temperatures ranged from 124.3 - 145.8 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in the basement and are inaccessible to clients. The last Fire/Emergency Drill was conducted on 06/9/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers located on each floor and were observed to be fully charged. Koi Ponds at facility are surrounded by a metal gate.
Operational Requirements: There is an outdoor activity area that is shaded and furnished for outdoor use, indoor activity room and movie room.
Staffing: There appears to be sufficient staffing at all times in the facility. Executive Director Daniel T. Konishi administrator certificate expires on 4/28/2024.
Personnel Records-Training: Staff has criminal record clearance and current CPR/first aid training, also have sufficient on-going training.
Resident Rights-Information: The facility provides internet and telephone access for the residents in care.
Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in medication carts and are in their original containers. During the visit today, LPA observed there to be an unlocked/unmonitored medication cart on the 2nd floor. LPA reviewed 12 residents’ medications no issues were observed.
Incidental Medical & Dental: All medications for residents are stored in a locked medication cart on the 2nd floor where the med room is.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
(continued on 809-C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAKURA GARDENS AT LOS ANGELES
FACILITY NUMBER: 198602192
VISIT DATE: 07/10/2023
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LPA conducted 5 staff interviews and 5 resident interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D.

Exit interview was held, a copy of the report and appeal rights were provided to Executive Director Daniel Konishi.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2023 03:45 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: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA toured resident rooms and tested water the water temperature reached 145.4 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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Executive Director Daniel Konishi to create a water temperature log and test the water temperature for the next 24 hours and document the readings. All readings must be consistant with Title 22 regulations and attain a temperature of 105 - 120 degrees F. This log is to be sumitted to LPA by email no later than end of business day 7/11/23.
Note: during todays visit Daniel had the water temp adjusted.
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed medictaion to be outside of the medication cart, medication cart was unlocked, making medications accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
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Med Techs immediately placed medications in medication cart and locked cart during visit. Executive Director Daniel Konishi to remind staff the importance of proper and safe storage of medication.
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: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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