435202531-12-21-2024-26-AS-KHOS-DCVT3K-20250113132229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202531
Report Date: 12/21/2024
Date Signed: 12/21/2024 10:41:30 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230907105608

FACILITY NAME:	SAKURA GARDENS VILLA LLC		FACILITY NUMBER:	435202531
ADMINISTRATOR:	KITAMURA, HIRO		FACILITY TYPE:	740
ADDRESS:	531 N CENTRAL AVE		TELEPHONE:	(408) 379-4110
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	15	CENSUS: 12	DATE:	12/21/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator, Beverly Canate		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility did not ensure resident safety, resulting in resident sustaining an injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Administrator, Beverly Canate and stated the purpose of today’s visit.

On 9/7/2023, the Department received a complaint with the above allegation. On 9/14/2023, the Department conducted an initial investigation at the facility.

It was alleged resident (R1) sustained injury which was a result of staff neglecting R1 on 9/5/2023.

On, 9/5/2023, the facility staff submitted an Incident Report for incident occurring on the same day for R1 who lost consciousness. Per report, staff were present and observed R1 losing consciousness and called 911 and informed R1’s responsible party.

Continuation on LIC 9099, Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

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 2

Control Number 26-AS-20230907105608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAKURA GARDENS VILLA LLC	FACILITY NUMBER: 435202531
	VISIT DATE: 12/21/2024

NARRATIVE

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On 9/14/2023, the Department interviewed 6 facility staff (S1-S6). All six staff stated on 9/5/2023, the resident lost consciousness during lunch time and staff were present in dining room and observed R1 and called 911 right away. Six out of six staff stated R1 was combative and sustained injuries when exhibited combative behavior. Six of six staff stated they have not seen or heard staff hurting or physically abusing R1 or other residents. Six out of six staff stated they have seen resident hurting or physically abusing R1 or other residents. Three of out the six staff provide direct care and supervision to R1. All three staff stated R1 has had combative behaviors where R1 will hurt themselves by hitting the side rails or the walls when R1 is agitated.

On 9/14/2023, the Department was not able to interview residents at the facility due residents not responding or refusing to answer LPA’s questions related to the investigation.

Based on review of R1’s documents, R1 has a neurocognitive disorder and history of skin bruising to due agitation. Based on review of R1’s Physician’s Report dated 5/17/2023, R1 is diagnosed with neurocognitive disorder and was diagnosed with nontraumatic subdural hematoma. Based on review of Incident Reports from 8/22/2023 – 9/5/2023, facility staff observed self-inflicted bruising due to R1 falling from bed.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Beverly Canate and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2