435202531-1-31-2024-26-AS-CDOS-CZZSJY-20240131125556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202531
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:56:03 PM

Document Has Been Signed on 01/31/2024 12:56 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

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: 13	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	HIRO KITAMURA		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Hiro Kitamura. During visit, LPA toured the facility to include the hallways, resident bedrooms, bathrooms, activity room, dining room, kitchen, and exterior. All staff present are fingerprint cleared and associated to the facility. LPA observed some exit routes were obstructed with a dresser, table with wheels, and a walker. Staff immediately moved the items to ensure the exit routes are free and clear of obstruction. Administrator was advised. Posters observed to include the complaint poster, ombudsman, and rights of resident council. Facility temperature maintained at 72 degrees Fahrenheit. The facility's fire extinguisher last serviced on 09/05/2023. Facility has smoke alarms and carbon monoxide detectors present throughout the hallways. The facility's hallways are lit up by natural light from the outside. Due to the overcast today, LPA observed the facility hallways where resident bedrooms are located were slightly dark. LPA obtained a photograph. Administrator states, during the night the hallways are lit up by 1 light at the end of each hall. LPA advised to install additional lighting in the hallways to ensure the residents safety and comfort during the night. Administrator stated understanding. Administrator also states during the night, they do not have any residents who wander and the residents are assisted with toileting. LPA observed the activity room, dining room, bathrooms, and resident bedrooms contained adequate lighting. Kitchen supplied with cups, plates, bowls, and utensils. The refrigerator temperatures maintained between 28 - 35 degrees Fahrenheit. The freezer temperatures maintained below 0 degrees Fahrenheit. Food items were observed covered and labeled. Facility has at least 2 days worth of perishables and 7 days with of non-perishable foods. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/31/2024

NARRATIVE

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Resident bedrooms were well maintained and free of clutter and odor. The bedrooms contained adequate lighting, bed, linens, chair, and dresser. LPA observed 2 resident beds contained half rails. LPA observed 2 out of 2 residents files contained an order for half rails.

Bathrooms supplied with hygiene products, paper supplies, and non-slid mats in the shower. The bathroom next to room #8 hot water temperature maintained at 108 degreed Fahrenheit. The bathroom next to room #3 hot water temperature maintained at 138 degrees Fahrenheit. Administrator was advised.

Facility has emergency back-up lighting throughout the hallways. Facility's emergency disaster plan was last updated in 2019. Administrator was advised to update their emergency disaster plan. LPA observed the facility conducts their emergency drills quarterly. The last drill was completed on December 2023. Facility has an infection control plan and sufficient amount of PPE supplies.

LPA reviewed 5 resident files. The resident files were observed complete, however, did not contain an appraisal/needs and services plan. Administrator states to be in the process of updating each resident's appraisal/needs and services plan and brought the records to another location. Administrator was advised to ensure the original copies are always in the facility during normal business hours. Administrator stated understanding. 5 out of 5 residents centrally stored medications and records observed maintained.

LPA reviewed 4 staff files. Staff files were completed to include an updated 1st aid certification, fingerprint clearance, health screening, and TB result. Staff are provided at least 20 hours of annual training to include but not limited to dementia, postural supports, medications, restricted health conditions, and hospice.

5 residents and 3 staff were interviewed.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Administrator, Hiro Kitamura and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2024 12:56 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAKURA GARDENS VILLA LLC	FACILITY NUMBER: 435202531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(d)

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review residents (R1 - R5)'s appraisal/needs and services plan was located in another location for updating, therefore, LPA Dolores was unable to review R1 - R5's appraisal/needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/07/2024
	Plan of Correction
1 2 3 4	Licensee will review section 87506(d) and submit a statement of understanding of the section cited. Licensee will submit the Plan of Correction written statement to LPA Dolores via email by POC due date of 02/07/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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