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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602192
Report Date: 05/26/2026
Date Signed: 05/26/2026 05:40:21 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
12/29/2025 and conducted by Evaluator Bonnie Tao
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251229160056
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: 127DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sweayen Tabayan, Memory Care DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to this facility. The initial visit was conducted by Licensing Program Analyst (LPA) Luis DeLeon on 01/06/2026. Upon arriving at the facility, LPA met with Resident Care Director Romeo Angeles. Shortly after, Memory Care Director Sweayen Tabayan joined the visit. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to them.

The investigation consisted of residents/witness/visitor/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and staff/ residents’ facility files.

The investigation revealed that, in regards of facility is in disrepair, it was alleged that the facility did not have proper emergency exits for residents. All fifteen (15) residents who were interviewed had never used the emergency exits and were not aware of any issue about it. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. (-continued on LIC 9099C-)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
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 5
Control Number 28-AS-20251229160056
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: 05/26/2026
NARRATIVE
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Per the physical plant tour, LPA Tao and Memory Care Director Sweayen Tabayan tested the emergency exits at the memory care unit. There are two emergency exits which were delay egress exits were not operable.

Administrator had placed work order to have technician coming out and fixing it tomorrow on 5/27/26.

Based on record review, observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Administrator Tomoko Hino. The findings were discussed. A copy of this report and appeal right were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20251229160056
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: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2026
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidenced by:
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Adminsitrator agreed to repair the emergency exits and work order was placed to hire techincian to repair the emergency exit. Adminsitrator will submit the proof of repair to licensing by the POC due on 5/29/26
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Per physical plant tour of memory care unit (Emil Brown Auditorium), two emergency exits with delay egress located at the entrance and back exit were not operable.

This poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
12/29/2025 and conducted by Evaluator Bonnie Tao
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251229160056

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: 127DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sweayen Tabayan, Memory Care DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff left resident in soiled diaper for an extended period.
Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to this facility. The initial visit was conducted by Licensing Program Analyst (LPA) Luis DeLeon on 01/06/2026. Upon arriving at the facility, LPA met with Resident Care Director Romeo Angeles. Shortly after, Memory Care Director Sweayen Tabayan joined the visit. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to them.

The investigation consisted of residents/witness/visitor/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and staff/ residents’ facility files.

The investigation revealed the following:

In regards of facility staff left resident in soiled diaper for an extended period, it was alleged that resident's diaper was not changed over the night. (- continued on LIC 9099C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251229160056
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: 05/26/2026
NARRATIVE
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Per the fifteen (15) residents who were interviewed, one (1) of them was unable to comprehend the interview questions, three (3) of them declined to be interviewed, one (1) of them was corroborated with the allegation and the rest of ten (10) residents could not corroborate with the allegation. It revealed that residents were not left in soiled diaper overnight. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. Per the interview with witness and visitor, they could not corroborate the allegation which revealed they were not aware of any resident who had sat in soiled diaper overnight. Per observation during the physical plant tour, no foul odors or soiled diapers were observed. Residents seemed clean and neat. No foul odor from residents was noted. Per record review, it revealed staff have a status check / log on residents who need incontinence care at least twice per shift and change residents’ diapers or pull ups throughout the day as needed.

In regards of facility staff did not administer resident's medication as prescribed, it was alleged that staff could not provide pain medication to resident during the night shift. Per the fifteen (15) residents who were interviewed, one (1) of them was unable to comprehend the interview questions, three (3) of them declined to be interviewed, and the rest of the eleven (11) residents could not corroborate with the allegation. It revealed that residents were able to get pain medication during the nighttime. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. Per the interview with witness and visitor, they could not corroborate the allegation which revealed they were not aware of resident who could not obtain medication at night shift. Per record review, residents’ medication log did not show missing medication. Therefore, there is no preponderance of evidence to prove the staff did not administer resident’s medication as prescribed.

Based on the information obtained during the investigation, interviews with staff/residents/witness/visitor, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Tomoko Hino. The findings were discussed and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5