Inspection Reports for Sakura Gardens of Los Angeles
325 S Boyle Ave, Los Angeles, CA 90033, United States, CA, 90033
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to environmental safety, medication management, and resident care, with several substantiated complaints over the past two years. The facility faced issues such as non-operable backup generators, improper medication administration including missed insulin and unprescribed drugs, inadequate supervision leading to resident injuries, and problems maintaining safe water temperatures. There were also repeated concerns about facility disrepair, including stolen wiring, broken air conditioning, and unsecured resident belongings. The most recent report from August 5, 2025, identified multiple deficiencies involving staff training, emergency preparedness, and documentation, but the environment and food services were compliant. While some improvements were noted after prior citations—such as correction of water heater issues—the overall pattern shows ongoing challenges in staff compliance and facility maintenance.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 125
Capacity: 183
Deficiencies: 8
Aug 5, 2025
Visit Reason
The visit was a continuation annual required inspection to evaluate compliance with licensing requirements for Sakura Gardens at Los Angeles, a residential care facility for the elderly.
Findings
Multiple Type B deficiencies were identified including missing health screenings, annual training, first aid certifications for staff, missing tuberculosis test results and ambulatory status in resident files, outdated reappraisals, an inoperable emergency backup generator, and lack of recent fire/earthquake/emergency drills. The facility environment and food services were found to be in compliance.
Severity Breakdown
Type B: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Five out of five staff files lacked a Health Screening form. | Type B |
| Three out of five staff files lacked verification of annual training including dementia training. | Type B |
| Three out of five staff files lacked verification of first aid certification. | Type B |
| Two out of five residents' files lacked Tuberculosis test results in physician's reports. | Type B |
| One out of five residents' files lacked ambulatory status in physician's report. | Type B |
| One out of five residents' files lacked an updated reappraisal for change of condition. | Type B |
| Disaster plan calls for use of an inoperable onsite backup generator. | Type B |
| No record of fire/earthquake/emergency drills since December 19, 2023. | Type B |
Report Facts
Staff files missing health screening: 5
Staff files missing annual training verification: 3
Staff files missing first aid certification: 3
Residents missing TB test results: 2
Residents missing ambulatory status: 1
Residents missing updated reappraisal: 1
Days of perishables supply: 2
Days of non-perishable food supply: 7
Fire extinguishers per floor: 2
Last fire extinguisher inspection date: Sep 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Director | Met during the inspection and received the report. |
| Alfonso Lozoya | Business Manager | Met during the inspection. |
| Fernando Fierros | Licensing Program Manager | Named as licensing program manager overseeing the inspection. |
| Luis DeLeon | Licensing Program Analyst | Conducted the inspection and signed the report. |
Inspection Report
Annual Inspection
Census: 125
Capacity: 183
Deficiencies: 3
Aug 4, 2025
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with licensing requirements for the facility serving elderly residents.
Findings
The inspection found deficiencies including failure to respond timely to resident call signals, hot water temperatures exceeding Title 22 regulations, and missing evacuation chairs at one stairwell, all posing immediate health and safety risks.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Two out of three call signals from residents' rooms were not responded to by staff. | Type A |
| Three out of seven bathrooms or common area sinks had hot water temperatures above 120 degrees Fahrenheit. | Type A |
| One out of two stairwells did not have an evacuation chair available. | Type A |
Report Facts
Call signals not responded: 2
Bathrooms/common area sinks with hot water above 120°F: 3
Stairwells missing evacuation chair: 1
Capacity: 183
Census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Director | Met during inspection and exit interview |
| Alfonso Lozoya | Business Manager | Met during inspection |
| Fernando Fierros | Licensing Program Manager | Named in report as licensing program manager |
| Luis DeLeon | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Census: 128
Capacity: 183
Deficiencies: 1
Jun 6, 2025
Visit Reason
An unannounced Case Management visit was conducted to address a repeat violation related to water temperature, following a previous licensing report and citation.
Findings
A repeat violation of CCR Section 87303(e)(2) due to water temperature was identified, resulting in an immediate civil penalty of $250 for failure to correct and repeat violations within 12 months.
Deficiencies (1)
| Description |
|---|
| Violation of CCR Section 87303(e)(2) due to water temperature |
Report Facts
Civil penalty amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robenion | Executive Director | Met with Licensing Program Analyst during visit and named in discussion of violations |
| Mayra Cota | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Plan of Correction
Census: 128
Capacity: 183
Deficiencies: 0
Jun 6, 2025
Visit Reason
The visit was a Plan of Correction (POC) unannounced inspection to verify correction of a previously cited deficiency related to water heater repairs.
Findings
The deficiency related to water heater temperature compliance was cleared by obtaining repairs and temperature logs. No new deficiencies were cited during this visit.
Report Facts
Number of resident bathrooms temperature checked: 12
Number of residents interviewed: 12
Number of staff interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the Plan of Correction visit and inspection |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 183
Deficiencies: 1
May 29, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not ensure hot water was available at the facility for residents in care.
Findings
The investigation substantiated the allegation that hot water was not adequately available, with water temperatures in 10 out of 14 resident bathrooms measured between 89.6 and 91.7 degrees F, below the required range of 105 to 120 degrees F. Residents and staff corroborated the issue, reporting inconsistent and insufficient hot water delivery.
Complaint Details
The complaint was substantiated based on evidence including water temperature measurements and interviews with residents and staff confirming the lack of adequate hot water for several days.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water supplies and plumbing fixtures were not maintained to deliver hot water at the required temperature range of 105-120 degrees F, with water temperatures measured between 89.9 and 91.7 degrees F in 10 resident bathrooms, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Resident census: 128
Total capacity: 183
Water temperature range: 89.6
Water temperature range: 91.7
Required water temperature range: 105
Required water temperature range: 120
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 183
Deficiencies: 1
Mar 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not ensure the facility generators were not in disrepair.
Findings
The investigation found that the facility generators had been non-operable for at least a year due to stolen copper wiring, causing a blackout lasting about two hours. The allegation was substantiated and a deficiency was cited for failure to maintain the facility in good repair, posing a potential health and safety risk to residents.
Complaint Details
The complaint was substantiated based on interviews, observations, and a tour of the facility. The generators were confirmed to be non-operable for at least one year due to stolen copper wiring, causing a blackout lasting two hours.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility generators were non-operable due to stolen wiring, resulting in the facility not being kept in good repair and posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 183
Census: 126
Deficiency count: 1
Plan of Correction due date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Executive Director | Interviewed during the complaint investigation regarding generator disrepair |
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 183
Deficiencies: 1
Feb 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-11-18 alleging that staff did not meet residents' needs and ignored residents' requests.
Findings
The investigation substantiated that staff failed to provide insulin and diabetic supplies to Resident #1, posing an immediate health and safety risk. Another allegation that staff ignored residents' requests was unsubstantiated based on interviews and observations.
Complaint Details
The complaint alleged that staff did not meet residents' needs, specifically failing to provide insulin and diabetic supplies to Resident #1, and that staff ignored residents' requests. The insulin-related allegation was substantiated, while the allegation regarding ignoring residents' requests was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide resident with insulin and diabetic supplies as required by regulation. | Type A |
Report Facts
Capacity: 183
Census: 126
Deficiencies cited: 1
Special Incident Report blood sugar level: 561
Plan of Correction due date: Feb 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Executive Director | Met during investigation and exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Follow-Up
Capacity: 183
Deficiencies: 1
Feb 13, 2025
Visit Reason
An unannounced case management visit was conducted due to deficiencies noted during a prior complaint visit on 2024-11-26.
Findings
The inspection found incomplete Medication Administration Record (MAR) logs for Resident 2, missing multiple initials for medications required daily or several times a day, posing potential health and safety risks.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incomplete MAR logs for Resident 2 missing multiple initials for medication administration required daily or several times a day. | Type B |
Report Facts
Capacity: 183
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Robeniol | Executive Director | Met with Licensing Program Analysts during the visit |
| Mayra Cota | Licensing Evaluator | Conducted the inspection and signed the report |
| Wei Siew Ho | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 183
Deficiencies: 0
Feb 4, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-12-04 regarding infection control, bed bugs, facility disrepair, food quality and quantity, and adherence to resident admission agreements.
Findings
The investigation found that staff were following infection control protocols despite a stomach virus outbreak, bed bugs were an isolated incident that did not spread, elevators were old but maintained with at least one working at all times, food quality and quantity were adequate with variety and options for seconds, and residents were properly notified about room moves with no rent increases. The allegations were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation addressed nine allegations including improper infection control, bed bug infestation, facility disrepair, inadequate food service, and non-adherence to admission agreements. Interviews with residents and staff, document reviews, and facility tours were conducted. The findings were unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 6
Facility capacity: 183
Facility census: 128
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jina Maleksarkissians | Administrator | Facility administrator interviewed during investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 183
Deficiencies: 0
Jan 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was sexually abused while in care.
Findings
The investigation found no sufficient evidence to substantiate the allegation of sexual abuse. Staff and residents denied witnessing or experiencing abuse, and medical tests initially indicating HIV positive were later corrected. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident with dementia was sexually abused while in care due to testing positive for HIV. The investigation included interviews with staff and residents, review of medical and facility records, and found no corroborating evidence. The allegation was unsubstantiated.
Report Facts
Capacity: 183
Census: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jina Maleksarkissians | Executive Director | Spoke with Licensing Program Analyst by phone regarding the visit |
| Alfonso Lozoya | Business Office Manager | Met with Licensing Program Analyst during the visit and received exit interview |
| Tomoko Hino | Marketing Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 141
Capacity: 183
Deficiencies: 0
Dec 19, 2024
Visit Reason
Licensing Program Analyst conducted an unannounced case management visit to tour the physical plant of the facility and assess its condition.
Findings
The facility was observed to be clean and in good repair with no deficiencies noted. Security improvements included welding shut back entrances of a former building and installing reinforced fencing with barbed wire.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomoko Hino | Sales Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Census: 141
Capacity: 183
Deficiencies: 1
Dec 9, 2024
Visit Reason
The inspection was conducted as a Case Management - Other visit related to complaint control 28-AS-20241204135046, focusing on observations made during a physical plant inspection.
Findings
The inspection found that three out of four bathrooms had hot water temperatures exceeding the required range of 105-120 degrees Fahrenheit, with temperatures measured between 132.3F and 134F, resulting in a citation being issued.
Deficiencies (1)
| Description |
|---|
| Hot water temperature in three bathrooms did not measure between the required range of 105-120 degrees Fahrenheit. |
Report Facts
Bathrooms with hot water temperature out of range: 3
Facility census: 141
Facility capacity: 183
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Generated the Case Management - Deficiencies report and conducted the inspection. |
| Alfonso Lozoya | Business Office Director | Met with the Licensing Program Analyst during the inspection. |
| Tony Vasallo | Supervisor | Named as supervisor in the report. |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 183
Deficiencies: 2
Sep 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the licensee did not ensure residents were provided with a comfortable environment and that the facility was in disrepair.
Findings
The investigation substantiated that the dining room air conditioning was inadequate, causing extreme heat and discomfort for residents, and that the air conditioning unit had been stolen about six months ago and not replaced, leaving the facility in disrepair.
Complaint Details
The complaint alleged that residents were not provided a comfortable environment due to inadequate air conditioning in the dining room and that the facility was in disrepair because the air conditioner had not been working for the past six months. The allegations were substantiated based on interviews and observations.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| A comfortable temperature for residents was not maintained at all times, with the dining room temperature being extremely hot a week prior, posing a potential health and safety risk. | Type B |
| The premises were not maintained in a state of good repair and did not provide a safe and healthful environment due to the stolen and unreplaced air conditioning unit. | Type B |
Report Facts
Capacity: 183
Census: 130
Deficiencies cited: 2
Plan of Correction Due Dates: 7
Plan of Correction Due Dates: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Administrator | Named in relation to findings about facility disrepair and air conditioning issues |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 130
Capacity: 183
Deficiencies: 0
Jun 28, 2024
Visit Reason
The inspection was an unannounced required 1-year annual visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.
Findings
No deficiencies were observed during the annual inspection. The facility was found to be in compliance with infection control, physical plant safety, operational requirements, staffing, personnel records, resident records, residents' rights, planned activities, food services, incidental medical and dental services, and resident special health needs. A technical violation will be provided for further information needed on the emergency disaster plan.
Report Facts
Residents files reviewed: 10
Staff files reviewed: 9
Residents receiving home health services: 5
Hospice waiver residents: 10
Facility capacity: 183
Census: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissian | Administrator | Administrator present during inspection; certificate pending renewal |
| Jose Villalobos | Licensing Program Analyst | Conducted the inspection |
| Fernando Fierros | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 130
Capacity: 183
Deficiencies: 0
Jun 25, 2024
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance using the full Care Compliance and Regulatory Enforcement (CARE) Tools.
Findings
The facility was found to have sufficient staffing with all staff over 18 years old and operational signal systems. Nine staff files were reviewed showing proof of training and certifications. The inspection was not completed due to time constraints and will continue at a later date.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissian | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Jose Villalobos | Licensing Program Analyst | Conducted the unannounced required 1-year visit using CARE Tools. |
Inspection Report
Complaint Investigation
Capacity: 183
Deficiencies: 4
May 17, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 11/20/2023 regarding inadequate supervision, improper medication dispensing, disrespectful staff behavior, and failure to safeguard residents' belongings at Sakura Gardens at Los Angeles.
Findings
The investigation substantiated several allegations including inadequate supervision leading to resident injuries, improper medication administration with increased dosages without physician orders, disrespectful and loud behavior by staff towards residents, and failure to safeguard residents' personal belongings during laundry. Some allegations related to failure to inform authorized representatives and failure to provide food or water were unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations received on 11/20/2023 concerning inadequate supervision, staff yelling at residents, disrespectful treatment, improper medication dispensing, and failure to safeguard personal belongings. The investigation included multiple visits and interviews, and substantiated several allegations while others were found unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide adequate care and supervision resulting in resident injuries on 11/3/23 requiring hospitalization and hip surgery. | Type A |
| Failure to treat residents with dignity and respect; staff yelling and mocking residents. | Type B |
| Failure to properly administer medications according to physician orders, including increasing frequency of behavioral medications without orders. | Type A |
| Failure to safeguard residents' personal property and valuables, including loss and misplacement of clothing due to laundry practices. | Type B |
Report Facts
Facility capacity: 183
Medication administration frequency: 3
Staff interviewed: 11
Plan of Correction due dates: May 18, 2024
Plan of Correction due dates: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Executive Director | Met during investigation and named in report |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
| Daniel Konishi | Administrator | Facility administrator named in report |
| S5 | Memory Care Unit Caregiver Staff | Named in findings for yelling at residents, disrespectful behavior, and improper handling of residents |
| S4 | Memory Care Unit Caregiver Staff | Named in findings for yelling at residents |
| S10 | Staff | Observed sitting on resident's walker and involved in disrespectful behavior |
| S11 | Housekeeper Staff | Found resident on floor after fall |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 183
Deficiencies: 2
May 9, 2024
Visit Reason
The inspection was conducted as a Case Management - Deficiencies visit in conjunction with complaint control #28-AS-20231120121606, focusing on observations made during the physical plant inspection of the Memory Care Unit.
Findings
Two deficiencies were identified: an open bottle of Listerine Antiseptic Mouthwash was found unsecured on a window seal posing an immediate health/safety risk, and a resident's Physician Report was outdated, lacking the required annual medical assessment for dementia care.
Complaint Details
The visit was triggered by complaint control #28-AS-20231120121606. The report includes substantiated deficiencies related to physical plant safety and medical assessment compliance.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Open bottle of Listerine Antiseptic Mouthwash found unsecured on window seal posing immediate health/safety risk. | Type A |
| Resident's Physician Report dated 02/02/2021, missing required annual medical assessment for dementia care. | Type B |
Report Facts
Capacity: 183
Census: 131
Plan of Correction Due Date: May 10, 2024
Plan of Correction Due Date: May 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Administrator | Met with during inspection and informed of report purpose. |
| Tyler Reyes | Licensing Evaluator | Generated the Case Management - Deficiencies report and conducted inspection. |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 183
Deficiencies: 2
May 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not provide a safe and comfortable environment for residents and that the facility was in disrepair.
Findings
The investigation substantiated that homeless individuals have been entering the facility campus through holes cut in fencing, squatting in an abandoned building on site, and causing safety and health risks. The facility was found to be in disrepair due to theft of copper wiring and damage to the backup power generator, phone, and fax lines, which affected resident phone service.
Complaint Details
The complaint investigation was substantiated. Homeless individuals were found to be entering the facility campus by cutting holes in fencing, squatting in an abandoned Intermediate Care Facility (ICF) building, and stealing copper wiring and other materials, causing safety and operational issues.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents were not afforded a safe, comfortable, and healthful environment due to homeless individuals entering the facility campus through holes in fencing. | Type B |
| The facility was not clean, safe, sanitary, or in good repair as the backup power generator, phone and fax lines, and dining hall AC units were damaged by theft and vandalism. | Type B |
Report Facts
Residents interviewed: 10
Staff interviewed: 4
Residents confirming phone issues: 2
Staff corroborating wiring tampering: 4
Facility capacity: 183
Facility census: 99
Plan of Correction due date: May 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Zaragoza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Jina Malesarkissians | Administrator | Facility administrator present during the investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 183
Deficiencies: 1
May 9, 2024
Visit Reason
The visit was a case management follow-up conducted after a complaint investigation related to incidents at the facility, including police being called and failure to submit required incident reports.
Findings
The facility failed to submit incident reports for multiple serious incidents including police calls, disconnection of resident phone lines, and theft of copper wiring and backup generator parts, posing potential safety risks to residents.
Complaint Details
The visit was triggered by a complaint investigation control #28-AS-20240501153246. The complaint was substantiated by findings of unreported serious incidents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit incident reports for events involving police being called, phone and fax disconnection, AC unit and backup generator dismantling, posing safety risks to residents. | Type B |
Report Facts
Capacity: 183
Census: 99
Plan of Correction Due Date: May 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Administrator | Facility administrator present during the inspection |
| Erik Zaragoza | Licensing Program Analyst | Conducted the case management visit and authored the report |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 183
Deficiencies: 0
Mar 20, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding the allegation that the administrator is not at the facility for the required amount of time.
Findings
The Licensing Program Analyst interviewed the administrator, staff, and residents and found that the administrator is generally available and present at the facility as required. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that the administrator was not available for residents and staff and was not in the building as required. After investigation, including interviews with the administrator, 6 staff, and 5 residents, the allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 183
Census: 129
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissian | Administrator | Interviewed during complaint investigation regarding administrator availability |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 183
Deficiencies: 1
Feb 8, 2024
Visit Reason
The inspection was conducted as a Case Management - Deficiencies visit related to complaint control #28-AS-20231120121606, focusing on observations made during the physical plant inspection of the Memory Care Unit.
Findings
The inspection found that all resident bedrooms in the Memory Care Unit had surveillance cameras installed in a wall corner of each room with wiring connected to electrical outlets, which was determined to be non-compliant with Title 22 regulations and posed potential health and safety risks to persons in care.
Complaint Details
The visit was triggered by complaint control #28-AS-20231120121606 and involved observations related to surveillance cameras in resident rooms.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| All resident rooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room with wiring that connects to electrical outlets, posing potential health and safety risks. | Type B |
Report Facts
Capacity: 183
Census: 134
Plan of Correction Due Date: Due date for correcting the cited deficiency is 02/15/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rodora Merana | Memory Care Director | Spoke with Licensing Program Analyst regarding the surveillance cameras |
| Noemi Galarza | Licensing Program Analyst | Generated the Case Management - Deficiencies report |
| Lisa Hicks | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 183
Deficiencies: 2
Feb 8, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate multiple allegations including staff interfering with residents' sleep, improper storage of residents' personal hygiene items, rushing residents during meals, and issues regarding the facility administrator's certification status.
Findings
Two allegations were substantiated: staff waking residents too early affecting their sleep, and improper storage of residents' hygiene products in the laundry room posing health and safety risks. Two allegations were unsubstantiated: staff rushing residents during meals and the facility administrator's certification status, as the Executive Director held a valid certificate despite no longer being employed.
Complaint Details
The complaint investigation was substantiated for allegations that staff interfere with residents' sleep by waking them too early and that residents' personal hygiene items were improperly stored in the laundry room. The allegations that staff rushed residents during meals and that the facility administrator lacked an active certificate were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Memory Care NOC shift staff waking residents between 4:30 AM - 5:00 AM, interfering with sleep. | Type B |
| Laundry room used as storage for residents' hygiene products, including toothbrushes and incontinence supplies, posing health and safety risks. | Type B |
Report Facts
Staff interviewed: 8
Staff interviewed: 7
Plan of Correction due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation. |
| Rodora Marina Merana | Memory Care Director | Interviewed during the investigation and assisted with the visit. |
| Daniel Konishi | Administrator | Former Executive Director mentioned in relation to administrator certification and facility management. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 183
Deficiencies: 5
Feb 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including resident falls due to staff neglect, failure to follow fall protocols, administration of medications not on the medication list, and failure to report falls to proper agencies.
Findings
The investigation substantiated multiple allegations: the resident sustained multiple falls due to staff neglect; staff failed to follow protocols regarding resident falls including notifying hospice and reporting to licensing agencies; and staff administered medication not prescribed to the resident. The facility failed to update or provide a fall prevention plan and did not report incidents within required timeframes.
Complaint Details
The complaint investigation was substantiated. Allegations included multiple resident falls due to staff neglect, failure to follow fall protocols, administration of unprescribed medication, and failure to report falls to hospice and licensing agencies. The facility failed to notify hospice of falls, did not follow hospice care plans, and did not report incidents within seven days as required.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure resident had a plan of care for fall risk after hospice documentation, posing immediate risk to health and safety. | Type A |
| Failure to ensure resident received medication as prescribed; resident was given acetaminophen 500mg not prescribed. | Type A |
| Failure to provide care and supervision meeting individual needs, including updating care plans and notifying staff. | Type A |
| Failure to follow protocol for resident care after falls on 1/15/24 and 1/24/24, posing potential risk to health and safety. | Type B |
| Failure to submit timely written reports to licensing agency and responsible persons regarding falls on 1/15/24 and 1/24/24. | Type B |
Report Facts
Facility capacity: 183
Resident census: 134
Incident dates: 2
Plan of Correction due dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Tomoko Hino | Sales Marketing Director | Met with Licensing Program Analyst during investigation and exit interview |
| Daniel Konishi | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Census: 133
Capacity: 177
Deficiencies: 0
Oct 10, 2023
Visit Reason
Subsequent Case Management Visit for Change of capacity to increase licensed capacity from 177 to 183 non-ambulatory residents.
Findings
The facility's physical plant meets Title 22 Regulations, fire clearance was approved for the increased capacity, and no deficiencies were noted during the visit.
Report Facts
Capacity increase: 183
Residents in Transitional Memory Care Units: 24
Residents in Memory Care Units: 23
Residents in Assisted Living: 136
Bedridden residents allowed: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Executive Director | Met with during visit and assisted with the capacity change visit |
| Tena Herrera | Licensing Program Analyst | Conducted the Subsequent Case Management Visit |
Inspection Report
Census: 132
Capacity: 177
Deficiencies: 1
Sep 26, 2023
Visit Reason
Licensing Program Analyst conducted a Case Management Visit for Change of capacity at Sakura Gardens at Los Angeles facility.
Findings
The facility was inspected for a capacity increase from 177 to 183 non-ambulatory residents. Several furnishing and maintenance issues were noted in the Transitional Memory Care Units, preventing approval of the capacity increase at this time.
Deficiencies (1)
| Description |
|---|
| Rooms 119-124 lacked proper furnishings such as bed, dresser, lamp, chair, shower curtain; air conditioner covers in rooms 119 and 120 were not properly secured; room 123 had debris and boxes; dining area lacked proper dining ware; insufficient linens available. |
Report Facts
Capacity change requested: 183
Current census: 132
Licensed capacity: 177
Number of rooms toured: 13
Bedridden residents allowed: 47
Residents in Transitional Memory Care Units: 24
Residents in Memory Care Units: 23
Residents in Assisted Living: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Executive Director | Assisted with the visit and was present during inspection |
| Tena Herrera | Licensing Program Analyst | Conducted the Case Management Visit |
| Rodora Marina Merana | Memory Care Director | Received a copy of the report during exit interview |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 177
Deficiencies: 0
Aug 22, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to allegations that staff were not safeguarding residents' personal belongings and not preventing residents' rooms from being broken into.
Findings
The investigation included interviews with the administrator, staff, and residents, and a review of a resident's file. The allegations were denied by staff and administrator, and residents were unable to corroborate the claims. There was no preponderance of evidence to prove the alleged violations, so the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not safeguarding residents' personal belongings and rooms being broken into. Interviews and evidence did not support the allegations.
Report Facts
Capacity: 177
Census: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Administrator | Administrator who assisted with the complaint investigation and was interviewed regarding the allegations |
| Angelica Rea | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Annual Inspection
Census: 131
Capacity: 177
Deficiencies: 2
Jul 10, 2023
Visit Reason
The visit was a required unannounced annual inspection conducted by Licensing Program Analyst Tena Herrera to evaluate compliance with regulatory standards at Sakura Gardens at Los Angeles.
Findings
The facility was generally compliant with infection control, staffing, personnel training, resident rights, and operational requirements. However, two deficiencies were noted: water temperature in resident rooms exceeded the regulatory maximum, and medications were found unsecured in an unlocked medication cart.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Water temperature in resident rooms reached 145.4 degrees F, exceeding the maximum allowed temperature of 120 degrees F, posing an immediate health and safety risk. | Type A |
| Medication cart was unlocked and medications were accessible to residents, posing an immediate health and safety risk. | Type A |
Report Facts
Residents present: 131
Total licensed capacity: 177
Water temperature: 145.4
Medication review: 12
Staff interviews: 5
Resident interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Executive Director | Named in relation to findings on water temperature adjustment and medication storage |
| Tena Herrera | Licensing Program Analyst | Conducted the inspection and documented findings |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 125
Capacity: 177
Deficiencies: 0
Jul 29, 2022
Visit Reason
The inspection was an annual unannounced visit focusing on the Infection Control domain to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with no deficiencies issued. The environment was clean, PPE supplies were adequate, infection control measures were in place, and medications were administered as prescribed.
Report Facts
Residents in Assisted Living building: 102
Residents in Memory Care unit: 23
Rooms inspected: 14
Hospice waiver capacity: 10
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Administrator | Met with Licensing Program Analysts during the inspection and provided information about facility operations |
| Cynthia Chan | Licensing Program Analyst | Conducted the annual inspection |
| Ya-Ting Yang | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Annual Inspection
Census: 123
Capacity: 177
Deficiencies: 0
Jul 19, 2021
Visit Reason
An unannounced Annual Required / Infection Control visit was conducted to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be in good repair with no observed deficiencies. Infection control practices were adequate, medications were properly stored, and the kitchen met regulatory standards. No citations were issued.
Report Facts
Water temperature range: 112
Water temperature range: 120.2
PPE supply duration: 30
Resident rooms inspected for water temperature: 13
Memory care wing capacity: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Alma Gonzalez | Licensing Program Analyst | Conducted the inspection visit |
| Rebecca Orendain | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 177
Deficiencies: 1
May 11, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 08/14/2020 regarding the facility's air conditioning being broken.
Findings
The investigation substantiated that the air conditioning in the Assisted Living building was broken due to a defective compressor, and the facility had installed a temporary chiller while awaiting a new HVAC unit installation completed on 09/18/2020. The air conditioning in the Memory Care building was functioning properly.
Complaint Details
The complaint was substantiated based on interviews with the Executive Director, residents, and review of HVAC repair quotes and documentation. The allegation was that the facility air conditioner was broken at or around 08/14/2020 and had also not been working the previous year (2019).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303(b) Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by the facility air conditioner not properly working and failure to ensure comfortable temperatures for residents, posing a potential safety risk. | Type B |
Report Facts
Capacity: 177
Census: 120
Plan of Correction Due Date: May 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Executive Director | Interviewed regarding the air conditioning issues and facility operations |
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Rebecca Orendain | Licensing Program Manager | Oversaw the complaint investigation report |
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