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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804033
Report Date: 01/23/2024
Date Signed: 01/26/2024 09:58:47 AM

Document Has Been Signed on 01/26/2024 09:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator- Jenna BaluyotTIME COMPLETED:
11:30 AM
NARRATIVE
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01/23/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Jenna Baluyot and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 117.5 F. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors.

LPA observed two of the four bed rooms to not have a bed. LPA observed two of the four residents to not have clothing in their room or a place to store such items. LPA observed no personal items or furnishings in one bedroom. LPA observed a hospital bed with bed rails in one of the four bedrooms with no medical order for the postural supports. LPA was told by the administrator that two of the four residents sleep in the common area of the home.

LPA reviewed a total of four (4) residents' files and five (5) staff files, which contained all the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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
Document Has Been Signed on 01/26/2024 09:58 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 01/23/2024 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 4 persons sleep in the living room per the Administrator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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The administrator will have the residents sleep in their room or request an exemption for these residents to sleep in common spaces.
Request Denied
Type A
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 4 residents do not have an individual bed in their room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Administrator will provide the residents with the appropriate required furnishings for all residents in care or obtain an exemption for these residents to not have a bed in their bedroom.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/26/2024 09:58 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 01/23/2024 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two of four residents did not have bedroom furnishings in their bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Administrator will provide the required furnishings for residents in care or obtain an exemption for these residents to not have furnishings in their bedrooms.
Request Denied
Type A
Section Cited
CCR
85088(c)(3)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (3) Portable or permanent closets and drawer space in each bedroom to accommodate the client's clothing and personal belongings.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of four residents did not have a furnishings to accomodate the clients clothing and personal belongings, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Administrator will provide the resident with the required furnishings to accomodate residents clothing and belongings or obtain an exemption for these residents to not have these furnishings in their bedroom.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/26/2024 09:58 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 01/23/2024 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAKURA HOME
FACILITY NUMBER: 486804033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of four residents had postural supports on their bed with no order from a medical provider, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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Administrator will obtrain a medical order for the postural supports or remove the postural supports.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
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