Inspection Reports for Sakura Gardens of Los Angeles

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.

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first aid certifications for staff, missing tuberculosis test results and ambulatory status in resident files, outdated reappraisals, an inoperable emergency backup generator, and lack of recent fire/earthquake/emergency drills.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.

The inspection was an unannounced required 1-year visit to evaluate compliance with licensing requirements for the facility serving elderly residents.

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.

An unannounced Case Management visit was conducted to address a repeat violation related to water temperature, following a previous licensing report and citation.

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.

The visit was a Plan of Correction (POC) unannounced inspection to verify correction of a previously cited deficiency related to water heater repairs.

The deficiency related to water heater temperature compliance was cleared by obtaining repairs and temperature logs. No new deficiencies were cited during this visit.

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.

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.

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.

The inspection was an unannounced complaint investigation triggered by an allegation that staff did not ensure the facility generators were not in disrepair.

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.

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.

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.

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.

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.

An unannounced case management visit was conducted due to deficiencies noted during a prior complaint visit on 2024-11-26.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was sexually abused while in care.

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.

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.

Licensing Program Analyst conducted an unannounced case management visit to tour the physical plant of the facility and assess its condition.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced required 1-year visit to evaluate compliance using the full Care Compliance and Regulatory Enforcement (CARE) Tools.

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.

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.

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.

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.

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.

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.

The visit was triggered by complaint control #28-AS-20231120121606. The report includes substantiated deficiencies related to physical plant safety and medical assessment compliance.

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.

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.

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.

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.

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.

The visit was triggered by a complaint investigation control #28-AS-20240501153246. The complaint was substantiated by findings of unreported serious incidents.

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.

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.

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.

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.

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.

The visit was triggered by complaint control #28-AS-20231120121606 and involved observations related to surveillance cameras in resident rooms.

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.

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.

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.

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.

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.

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.

Subsequent Case Management Visit for Change of capacity to increase licensed capacity from 177 to 183 non-ambulatory residents.

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.

Licensing Program Analyst conducted a Case Management Visit for Change of capacity at Sakura Gardens at Los Angeles facility.

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.

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.

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.

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.

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.

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.

The inspection was an annual unannounced visit focusing on the Infection Control domain to evaluate compliance with licensing requirements for the facility.

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.

An unannounced Annual Required / Infection Control visit was conducted to evaluate the facility's compliance with health and safety regulations.

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.

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.

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.

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).