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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602192
Report Date: 03/02/2026
Date Signed: 03/02/2026 01:52:16 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
02/25/2026 and conducted by Evaluator Gabriela Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260225102337
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: 135DATE:
03/02/2026
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Tomoko Hino, Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not following proper reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 03/02/2026 to deliver findings related to the above allegation. LPA met with Administrator Tomoko Hino and explained the purpose of the visit.

The investigation included a review of the client roster, staff roster, R1’s face sheets, and R1’s physician’s report. Additionally, the LPA reviewed Internal Incident Report and Narrative Charting Records regarding R1. The LPA also conducted interviews with four staff members (S1–S4).


(continued 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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 3
Control Number 28-AS-20260225102337
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: 03/02/2026
NARRATIVE
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Allegation: Staff are not following proper reporting requirements

It is alleged that the facility failed to comply with regulatory reporting requirements regarding incidents involving R1. During staff interviews (S1–S4), staff reported the following reporting procedures: Staff are required to report incidents directly to their supervisor and provide factual information regarding incidents that occur during their shifts. Staff complete Narrative Charting and an internal incident report form following an incident. These reports are submitted to the supervisor, who is responsible for submitting an Unusual Incident Report to Community Care Licensing (CCL).

During the record review of documents provided by the facility, there were no Unusual Incident Reports on file regarding any incidents involving R1. The facility did provide Narrative Charting summaries dated January 27, 2026 (a.m. shift), in which two staff members documented that R1 may have fallen in her room and that R1 was observed the following day with a bruise to her right eye. An additional internal incident report dated January 28, 2026 (a.m. shift) documented that staff observed R1 with a black eye.



Additionally, a Narrative Charting entry dated February 11, 2026, indicated that an altercation occurred between R1 and their roommate, during which R1 was reported to have hit their roommate. No Unusual Incident Reports were present in R1’s file, and the facility did not have records indicating that Unusual Incident Reports were completed for these incidents. Community Care Licensing also does not have records of ever receiving Unusual Incident Reports for either of these incidents.

Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260225102337
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: 03/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2026
Section Cited
CCR
87211(a)(1)(D)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events.
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Administrator will submit Unusual Incident Reports involving R1 by POC due date. Administrator will also verify that all future reportable incidents are submitted to CCL within seven (7) days.
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(D) Any incident which threatens the welfare, safety or health of any resident...
This requiment is not met as evidenced by: Based on record review and interviews, the facility failed to submit Unusual Incident Reports to CCL for incidents involving R1 as required.
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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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Gabriela Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3