Sakura Gardens at Los Angeles

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency (D) Any incident which threatens the welfare, safety or health of any resident.This requirement is not met as evidenced by: Based on record reviews, there were no incident reports provided to licensing for R1's related falls which poses a potential health and safety risk to residents in care.

87209 Program Flexibility (a) The use of alternate concepts, programs, services, procedures, techniques...(2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee. Based on interview, the facility did not have a waiver regarding the use of video surveillance in the residents' rooms which poses a potential personal rights risk to residents in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events. (D) Any incident which threatens the welfare, safety or health of any resident...This requiment is not met as evidenced by: Based on record review and interviews, the facility failed to submit Unusual Incident Reports to CCL for incidents involving R1 as required.

Facility personnel sufficiency and competence

(a) PERSONNEL REQUIREMENTS. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This standard is not met as evidence by:Staff did not seek timely medical care for R-1 after R-1 fell which resulted in a fractured right hip.Civil penalty issued.

Regular observation and documentation of resident changes

Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This standard is not met as evidenced by: R-1 had at least (11) known fall incidents and staff did not have R-1 reassessed.

Based on interview and record review, the licensee did not comply with the section cited above for the disaster plan calls for the use of the onsite backup generator which is currently inoperable and unavailable for use during a disaster which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in three (3) out of five (5) staff files which did not have a verification of annual training, including dementia training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents files did not have an updated reappraisal for change of condition for R4 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents files did not have an ambulatory status for R5 on physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

Record findings for communicable tuberculosis conditions

Based on record review, the licensee did not comply with the section cited above in two (2) out of five (5) residents' files which did not have Tuberculosis test result in physician's report for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above in five (5) out of five (5) staff files did not have a Health Screening form which poses/posed a potential health, safety or personal rights risk to persons in care.

First aid training requirements

Based on record review, the licensee did not comply with the section cited above in three (3) out five (5) staff files which did not have a verification of first aid certification, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above as there is no record of any fire/earthquake/emergency drills being done at the facility since December 19, 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation and interview, the licensee did not comply with the section cited above in three (2) out of seven (7) bathrooms/or common area sink temperature were above 120 degrees Farenheith which poses an immediate health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

Based on observation and interview, the licensee did not comply with the section cited above as two (2) out of three(3) call signals from residents rooms were not responded by staff which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in one (1) out of two (2) stairwells did not have an evacuation chair available which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).The licensee did not comply with the section cited above as water temperature in 10 resident's bathrooms measured at 89.9 and 91.7, which poses an immediate health, safety or personal righs risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and OperationsThe 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: Based on interviews conducted, tour conducted and information gathered the facility was not kept in good repair with generator non-operable which poses a potential health and safety risk to residents in care.

Diabetes 87628(b)(1): (b) In addition to Section 87611, General Requirements by Allowable Health Conditions, the licensee shall ... : (1) Assisting residents with self-administered medication as specified in Section 87465, Incidental Medical ... Services. This requirement is not met as evidenced by: Based on observation, file and record review, and interviews conducted, Licensee did not provide resident with insulin and diabetic supplies which poses an immediate health, safety, or personal rights risk to persons in care.

Maintain separate complete record for each resident

Resident Records 87506(a) Licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ... readily available to facility staff and to licensing ... This requirement is not met as evidenced by: Based on file and record review of R2's MAR logs were incomplete. MAR logs were missing multiple initials for medication required to be administered daily, once or several times a day, which poses a potential health, safety, or personal rights risk to persons in care.

Provide resident hot water for personal care

87303 Maintenance and Operation(e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on Observations three (3) out of four (4) bathrooms hot water did not measure between the required range of 105-120 degree.

Facility maintenance and healthful environment

Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement is not met as evidenced by: Based on observation and interview, the Licensee / Administrator did not comply with the section cited above. A/C unit was stolen about 6 mouths ago and until today was not replaced / restored

Maintain comfortable room temperature at all times

Maintenance and Operation.(b) A comfortable temperature for residents shall be maintained at all times.This requirement is not met as evidenced by: Based on observation and interviews, the Licensee / Administrator did not comply with the section cited above.Dining room temperature was extreme hot a week ago, which poses a potential health and safety risk to residents in care.

Dignity in personal relationships

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: Based on interviews, the findings revealed that staff (S5) yells at residents, is impatient, and mocks Memory Care residents, and multiple residents are not treated with respect and dignity due to S5 & S10's behavior, this poses a potential health and safety risk.

Facility must safeguard entrusted cash and valuables

Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement was not met evidenced by: Based on interviews conducted, residents clothing and bedding linens are being misplaced or lost because in order to save time Memory Care staff are washing residents clothing/bedding items together, and sometimes items are not returned after being laundered, which poses a potential health and safety risk to persons in care.

Give PRN medication by physician order

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all .... requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review and interviews, Memory Care Director instructed med-tech staff to increase the frequency of medication administration of behavioral medication Quetiapine (Seroquel) to residents (R2 & R3) without a physician order; which poses an immediate health and safety hazard to the residents.

Regular observation and documentation of resident changes

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidenced by: Based on records review and interviews conducted, staff failed to provide provide adequate care and supervision, resulting in injuries that occurred on 11/3/23 to R1 that required hospitalization and hip surgery. This is an immediate health and safety risk to the residents in care.

Care of Persons with Dementia (g) residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1)Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. Based on LPA's observation during the tour of the physcial plant at 11:18am in room number 1010 an open bottle of Listerine Antiseptic Mouthwash on the window seal was observered. The poses an immediate health/safety risk to the residents in care.

(a) Each licensee shall furnish to the licensing agency (...) (1) A written report shall be submitted to the licensing agency (...) within seven days of (...) (D) Any incident which threatens the welfare, safety, or health of a resident. Based on record review and interview, the LPA determined that the facility did not submit incident reports for events involving police being called to the facility, along with the phone, fax, AC unit, and backup generator being dismantled, which poses a potential safety risk to residents.

Safe, healthful, comfortable accommodations

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on observation and interview, LPA determined that homeless individuals have been entering the campus of the facility through holes cut into the fencing along the 101 freeway and also along the ICF building, which poses a potential health and safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

(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: Based on observation and interview, LPA determined that the facilities phone lines, fax lines, backup power generator, and also dining room AC units have been damaged by individuals stealing their parts, which poses a potential health and safety risk for residents in care.

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. Based on LPA's record review of R1's file the Physician's Report dated 02/02/2021 it was observed that the resident did not have an annual medical assesment, as required for Dementia residents; which poses a potential health and safety risk to residents in care.

Maintenance and Operation. Facilities which have machines and do their own laundry shall: ... Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noises shall not reach resident or employee areas Based on observation, the laundry room is being used as a storage room for resident's hygiene products i.e. toothbrushes, incontinence care; which poses a potential health and safety risk to persons in care.

Protection from punishment and intimidation

Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met evidenced by: Based on interviews conducted, the findings indicate that Memory Care NOC shift staff are waking up the residents between 4:30 AM - 5:00 AM, in order to get them ready and transported to the dining room at 6:00 AM, which interferes with sleeping. This poses a potential health and safety risks to persons in care.

Living accommodations aligned with facility function

Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement was not met evidenced by: Based on observation, 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. This poses a potential health and safety risks to persons in care.

87705 Care of Persons with Dementia(c) Licensees...shall be responsible...: (4) ...direct care staff to support each resident’s physical, social, emotional, safety and health care needs...This requirement is not met as evidence by: Based on documents review and interviews licensee did not ensure to follow protocol for R1 after falls obtained on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents...: (a)...residents...: (4) To care, supervision,... meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...This requirement is not met as evidence by: Based on interviews conducted and documents review licensee did not ensure that R1 had a plan of care for fall risk after hospice documented which poses an immediate risk to the health, safety, or personal rights of the persons in care.

Give PRN medication by physician order

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable...: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on documents review and interviews licensee failed to ensure that R1 received medication as prescribed and was given acetaminophen 500mg on 1/24/24 which poses an immediate risk to the health, safety, or personal rights of the persons in care.

Report specified resident events within seven days

87211 Reporting Requirements a) Each licensee shall ..: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidence by: Based on documents review and interviews conducted licensee failed to inform CCLD and physician (hospice agency) regarding falls ocurred on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above as LPA observed medictaion to be outside of the medication cart, medication cart was unlocked, making medications accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above as LPA toured resident rooms and tested water the water temperature reached 145.4 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain comfortable room temperature at all times

87303(b) Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times.This requirement was not met as evidenced by: Based on interviews and review of documents that confirmed that the facility air conditioner was not properly working and the licensee did not ensure that the temperatures of resident rooms were kept at a comfortable temperature, which poses a potential safety risk to residents in care.