Sakura Gardens at Los Angeles

COMPLAINT INVESTIGATION REPORT

FACILITY EVALUATION REPORT

The complaint investigation, conducted on 03/02/2026, substantiated the allegation that staff are not following proper reporting requirements. The primary deficiency found was the failure to submit required Unusual Incident Reports to Community Care Licensing for documented incidents involving the resident, R1. The facility must correct this by submitting all required reports by the Plan of Correction due date.

This was a Case Management visit conducted following a complaint investigation regarding resident falls. The primary deficiency cited relates to the failure to adequately observe and reassess the resident following multiple fall incidents. The facility must implement a plan to ensure regular observation and appropriate follow-up care for changes in the resident's condition.

This was a Case Management visit conducted following a complaint investigation regarding resident falls. The primary deficiency cited relates to the failure to adequately observe and reassess the resident following multiple fall incidents. The facility must implement a plan to ensure regular observation and appropriate follow-up care for changes in the resident's condition.

The inspection identified multiple deficiencies across several areas, including staff recordkeeping, resident medical documentation, and emergency preparedness. All cited deficiencies were classified as Type B, indicating non-compliance that could become a risk if not corrected. The facility must address documentation gaps for health screenings, training, first aid, and update its disaster and emergency drill records.

The facility was inspected for a required 1-year review and was found to have multiple deficiencies. Three Type A deficiencies were cited, including failures in call signal response, excessive hot water temperatures, and missing evacuation equipment. These issues represent immediate risks to the residents' health and safety.

The visit was an unannounced Case Management review. The primary finding relates to repeated violations concerning water temperature, specifically citing a previous notice from 12/9/2024 and a repeat violation on 5/29/25. Due to the repetition of this violation within the 12-month period, an immediate civil penalty of $250 was assessed.