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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602192
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:57:51 PM


Document Has Been Signed on 02/08/2024 04:57 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
CCLD Regional Office, 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:183CENSUS: 134DATE:
02/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Rodora Merana, Memory Care DirectorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control #28-AS-20231120121606 pertaining to observations made during the physical plant inspection of the Memory Care Unit. The purpose of the report was explained to Memory Care Director Rodora Merana.

All resident bedrooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room. The cameras have wiring that connects to electrical outlets.

LPA spoke with Rodora Merana and she stated that the cameras were donated, but it was determined to be non-compliant with Title 22 regulations. However, maintenance staff have not removed the cameras from the resident rooms. No Exception Waiver has been submitted to the department. Per Title 22, residents shall be afforded privacy.

Based on observation, a citation is being issued. See LIC 809D.

An exit interview was conducted and a copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 04:57 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
CCLD Regional Office, 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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87307(a)

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Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement was not met evidenced by:
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Facility shall remove all surveillance cameras from the Memory Care Unit resident rooms, and/or if applicable may submit an exception waiver for surveillance cameras for specific residents. Please submit a written POC and picture proof evidence that the cameras were removed from all resident rooms.
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Based on observation, all resident rooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room with wiring that connects to electrical outlets. This poses a potential health and safety risks 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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