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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202531
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:48:51 PM

Document Has Been Signed on 01/21/2025 01:48 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 LLCFACILITY NUMBER:
435202531
ADMINISTRATOR/
DIRECTOR:		KITAMURA, HIROFACILITY TYPE:
740
ADDRESS:531 N CENTRAL AVETELEPHONE:
(408) 379-4110
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 15CENSUS: 11DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Staff, Tomoko YoshidaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct the facility's Required 1-Year annual inspection. LPA met with Staff Tomoko Yoshida. LPA toured the facility to include the hallways, resident bedrooms, bathrooms, recreation room, dining room, kitchen, and exterior. All staff present are fingerprint cleared and associated to the facility. LPA observed 5 residents in the recreation room watching tv and reading the newspaper.

LPA observed the hallway temperature display at 71 degrees Fahrenheit. LPA observed 2 hallway exit routes are lit with sunlight from the windows above the hallway. LPA observed posters for complaint reporting, ombudsman, and Resident's Rights.

LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 40 degrees F and freezer maintained at 0 degrees F.

At 10:16AM LPA observed a damaged and discolored kitchen countertop area where food is prepared, next to the kitchen sink. LPA advised staff to repair counter top and to ensure the facility is in good repair.

LPA toured 15 resident bedrooms. 14 out of 14 resident bedrooms had a bed, functioning lights, a dresser/table, a chair and space for personal belongings. 1 resident bedroom is being used as storage. LPA advised staff to update the facility sketch and submit to the Department by 1/31/2025. LPA measured water temperature for 6 resident bathrooms at 105 degrees F. LPA observed spider webs in the ceiling of the bathrooms, and dark spots on the shower floor (next to bedroom #8). LPA advised staff to ensure the facility is in good repair at all times.

See LIC809-C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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: 01/21/2025
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LPA reviewed 3 staff records. 3 out of 3 staff records were complete and included background fingerprint clearance, health screening with TB result, staff training and first aid certification.

LPA reviewed 4 resident records. 4 out of 4 resident records were complete and included emergency contact information, medical assessments, and needs and service plans. LPA also reviewed 4 Centrally Stored Medication and Destruction Records (CSDMRs). 4 out of 4 CSMDRs were observed to be complete with all medication documented accurately.

LPA reviewed emergency drill logs. LPA observed the facility conducts their emergency drills quarterly. The last drill was completed on 1/16/2025. The facility's last fire inspection was conducted on 3/28/2024. The facility's fire extinguisher was last serviced on 09/05/2024. Facility has smoke alarms and carbon monoxide detectors present throughout the hallways.

LPA requested the facility submit an updated facility sketch to the Department by 1/31/2025.

A deficiency was cited today per California Code of Regulations, Title 22. See LIC809D. This report was reviewed with Staff Tomoko Yoshida and copy of this signed report and appeal rights were provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 01:48 PM - It Cannot Be Edited


Created By: Marcella Tarin On 01/21/2025 at 01:29 PM
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
, 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. During inspection, LPA observed a damaged and discolored kitchen countertop next to the sink, spider webs in the ceiling of the bathrooms, and dark spots on the shower floor (next to bedroom #8), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee will conduct an in-service training with staff on maintenance and operation to ensure the health and safety of all residents in-care by 1/22/2025. Licensee will submit POC to include a date for the repair of the kitchen countertop and training documentation to the Department by 1/22/2025.
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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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