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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920092
Report Date: 01/21/2025
Date Signed: 01/21/2025 12:50:27 PM

Document Has Been Signed on 01/21/2025 12:50 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAKURA HOME CAREFACILITY NUMBER:
315920092
ADMINISTRATOR/
DIRECTOR:		MALITSKIY, JULIEFACILITY TYPE:
740
ADDRESS:1220 HORTON LNTELEPHONE:
(279) 900-8464
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Julie Malitskiy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility and met with Administrator, Julie Malitskiy, to conduct a case management visit in relation to a separate inspection conducted on 12/12/2024.

LPAs observed that resident R2's LIC 602A dated 10/3/2024 indicates R2 does not have bowel or bladder impairment with written comments stating "needs assistance getting there." R2's LIC 602A states R2 is able to bathe, dress, groom, feed, and toilet themselves with written comments stating "may need some assistance." R2 is listed as nonambulatory. R2 is able to communicate their own needs and has no cognitive impairment. Interviews with Staff members S1 and S2, Administrator, and R2 indicated that R2 needed assistance with bathing, dressing, grooming, feed, and toileting. LPAs inquired about the discrepancies in R2's documents with Administrator. Administrator stated that R2 was admitted without Administrator obtaining a copy of R2's LIC 602A.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
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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Document Has Been Signed on 01/21/2025 12:50 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 01/21/2025 at 12:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAKURA HOME CARE
FACILITY NUMBER: 315920092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
CCR
87458

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional (...). This requirement is not met as evidenced by:
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Facility obtained a updated LIC 602A for R2 on 01/03/2025 that is consistent with R2's care. LPA cleared deficiency at the conclusion of this visit.
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Based on interviews conducted, LPAs' observations, and records reviewed, the facility did not ensure to obtain a medical assessment for R2 prior to admission, which poses a potential health, safety, and personal rights risk to residents in care.
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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:Laura Munoz
LICENSING EVALUATOR NAME:Cassandra Mikkelson
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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