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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600836
Report Date: 10/14/2019
Date Signed: 10/14/2019 05:21:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 6DATE:
10/14/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Miho Takahashi & Keiko Konno, Hiro Kitamura & Ron MoyTIME COMPLETED:
05:30 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
[2]LPAs Audrey Jeung and Sarena Keosavang toured facility and grounds, including second floor living unit, where sub-tenant resides. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and lighting is sufficient for comfort and safety. Hot water temperature is tested at 109 degrees in bathroom in room 4. Food supply, signal system, and first-aid kit are inspected. Some client files are reviewed. Medications will be reviewed at a later date. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Staff training records will be reviewed at a later date. Hiro Kitamura and Ronald Moy are certified RCFE administrators (x10/20 & 6/21) that oversee facility operations.

The following forms are to be completed and returned to CCL by 10/21/19:

• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan

Administrators are advised that Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative.

As per legislation, effective 1/1/2015, the following information is posted: 1) PUB474, pertaining to resident councils, per AB1572; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 3) CCLD Hotline information, per SB895..

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on page THREE.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAKURA GARDENS
FACILITY NUMBER: 415600836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2019
Section Cited

1
2
3
4
5
6
7
POSTURAL SUPPORT
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
This requirement is not met as evidenced by absence of MD order for Client 4 half bed rails. Licensee failed to ensure that MD orders are maintained for 1 out of 2
8
9
10
11
12
13
14
clients who use half bed raills, which poses a potential health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAKURA GARDENS
FACILITY NUMBER: 415600836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2019
Section Cited

1
2
3
4
5
6
7
OXYGEN ADMINISTRATION
Oxygen tanks that are not portable shall be secured in a stand or to the wall.
This requirement is not met as evidenced by observation of two tanks under bed room 6.
8
9
10
11
12
13
14
Licensee failed to ensure that oxygen tanks are secured in a stand or to a wall, which posses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
10/21/2019
Section Cited

1
2
3
4
5
6
7
ADMISSION AGREEMENTS
Admission agreements shall specify rate for all basic services which the facility is required to provide in order to obtain and maintain a license.
This requirement is not met as evidenced by review of 4 residents records. Licensee failed to ensure that 2 clients' admission
8
9
10
11
12
13
14
agreements include monthly rate, which posses a potential health, safety, or personal rights risk to residents in care. No monthly rates on admission agreement on clients 1 and 6.
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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3