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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804033
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:10:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20241030105747
FACILITY NAME:SAKURA HOMEFACILITY NUMBER:
486804033
ADMINISTRATOR:JENNA BALUYOTFACILITY TYPE:
735
ADDRESS:2124 TILDEN PLACETELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elinore Ramas, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 02/20/2025, at approximately 10:00 AM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to deliver findings for the above allegation. Reporting Party (RP) alleges that Facility staff slapped Client 1 (C1) resulting in injury to C1.

LPA made initial contact via telephone with RP on 10/30/2024 at which time RP stated they did not have any additional information to add to the complaint investigation. LPA conducted 10-day investigation visit on 10/31/2024 and conducted interviews, made observations, and obtained documents. LPA was able to interview the Administrator and Staff 1 (S1). Clients were unable to be interviewed due to their intellectual disabilities. Subsequent interviews were conducted with Administrator, Staff 2 (S2), and Staff 3 (S3) on 02/13/2025. The interviews conducted and records reviewed provided corroborating information regarding the above allegation.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 3
Control Number 21-AS-20241030105747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033
VISIT DATE: 02/20/2025
NARRATIVE
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Continued from LIC9099...

LPA’s interview with S3 revealed that S3 did not allow C1 to call their responsible party when requested and implemented manual restraint to C1 while attempting to deescalate C1's aggressive behaviors which resulted in at least 4 red marks being left on the left side of C1's face. Per staff interviews and record review, manual restraint is not an approved method of intervention in C1's behavior plan or care plan.

Based on interviews conducted, observations made, and record review, the allegations listed above are SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from California Code of Regulations, Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241030105747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) ...each client shall have personal rights which include... (2) To be accorded safe...accommodations ... and equipment to meet his/her needs.

This requirement is not met as evidenced by:
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Licensee to submit self certification that all staff will be trained on preventative measure, Client's personal rights, and deescalation tactics to CCL by POC due date 02/21/2025. Licensee to then submit proof of training such training to CCL by POC dues date 03/21/2025.
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LPA’s interview with S3 revealed that S3 did not allow C1 to call their responsible party when requested and implemented manual restraint to C1 while attempting to deescalate C1's aggressive behaviors which resulted in at least 4 red marks being left on the left side of C1's face.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3