<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600836
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:43:47 AM


Document Has Been Signed on 09/20/2024 11:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SAKURA GARDENSFACILITY NUMBER:
415600836
ADMINISTRATOR:KITAMURA, HIRO/MOY, RONFACILITY TYPE:
740
ADDRESS:2108 ISABELLE AVENUETELEPHONE:
(650) 525-1795
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver - Maureen Hori and Seiichi HoriTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/20/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with caregivers Maureen Hori and Seiichi Hori. There are currently 4 residents in the facility during today's visit and 2 staff present including the administrator.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 4 hospice residents. There are 2 hospice residents as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer next to the stove. Perishable and non-perishable food items are observed as needing more items to sustain the 7 day non-perishable. The pantry only contained a few canned goods and some dry goods that would not meet 7 days of use. This poses a potential health and safety risk to residents in care. There is an additional freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet. LPA observed at least two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is equipped with fire sprinklers through out. LPA also observed fire pull stations in the rear and front of the facility. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill logs are not available for review per staff. Staff indicate they've worked in the facility about 5 to 7 months and they have not conducted such drills. This poses an immediate health and safety risk. Water temperature was measured at 110F. Cleaning supplies are observed to be locked in the kitchen and garage.

Continued on next...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAKURA GARDENS
FACILITY NUMBER: 415600836
VISIT DATE: 09/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files which are current. No staff files are able to be reviewed. Per staff, the staff files are not on site for review. LPA is also unable to determine first aid training information, and training information, but according to staff they do have it just not on site to provide for review. Administrator certificates are observed within the facility for several people including the licensee Hiro Kitamura exp 10/01/2024, Ronald Moy exp 06/20/2025, and Mashu Kitamura exp 06/07/2018. Staff are unsure if the administrator certificates have been renewed for Hiro or Mashu. Per staff, Ronald provides oversight mainly at this time. Both Ronald and Hiro are able to be contacted by telephone per staff.

The following updated forms are requested to be submitted to CCLD by 09/27/2024:

• Copy of all updated administrator certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Citations are issued on this day on the attached LIC809D pages. Report is reviewed with staff person Seiichi and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/20/2024 11:43 AM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SAKURA GARDENS
FACILITY NUMBER: 415600836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
HSC
1569.695(c)

1
2
3
4
5
6
7
1569.695(c) Emergency Plans - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code section has not been met as evidenced by:
1
2
3
4
5
6
7
The licensee will develop a plan to ensure compliance with this health and safety code section and will provide a copy of the plan to CCL by 09/21/2024 and the plan shall indicate when the drill will be conducted and to continue doing the drills quarterly.
8
9
10
11
12
13
14
Based on interviews with staff, the staff do not have a log to provide for review. Both staff indicated that they have been working at the facility for about 5 to 7 months and they have not conducted such drills. This poses an immediate health and safety risk to the residents in care.
8
9
10
11
12
13
14
Type B
09/23/2024
Section Cited
CCR87412(f)

1
2
3
4
5
6
7
87412(f) Personnel Records - (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
The licensee shall develop a written plan ensuring that staff files are available on site for review by the Department at all timess. This plan shall be submitted to the Department by 09/23/2024.
8
9
10
11
12
13
14
Based on file reveiws and interviews with staff, the staff do not have staff files on site available for review. It was stated that the licensee/administrator have the files and they are not present for review. This poses a potential health and safety risk.
8
9
10
11
12
13
14
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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/20/2024 11:43 AM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SAKURA GARDENS
FACILITY NUMBER: 415600836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
87555(b)(26)

1
2
3
4
5
6
7
87555(b)(26) General Food Service Requirements - Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met, as there are only 5 cans of fruit maintained for 7-day. This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
The licensee will develop a plan to ensure compliance with this health this regulation at all times and provide evidence/proof of replenishing the canned goods and dry goods to ensure a stable 7 day emergency supply is on site at all times. A copy of this plan shall be received by 09/23/2024.
8
9
10
11
12
13
14
Based on observations made of food supplies, its observed that there is not enough canned food or dry goods in place to sustain 7 days in the event of an emergency. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
09/23/2024
Section Cited
CCR87411(c)(1)

1
2
3
4
5
6
7
87411(c)(1) Personnel Requirements - General - Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee shall ensure that proof of first aid training is current and provided to the Department for review. A plan shall also be developed to ensure that copies of all statt first aid training is kept on site along with other staff training records for review. A copy of this plan, and staff first aid certificated shall be received by 09/23/2024.
8
9
10
11
12
13
14
Based on file reviews attempted, there is no staff file on site for LPA to review ensuring first aid training has been conducted in order to ensure staff have this training. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4