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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802134
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:35:10 PM

Document Has Been Signed on 01/08/2025 01:35 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNRISE TERRACE RCFE VIIFACILITY NUMBER:
405802134
ADMINISTRATOR/
DIRECTOR:		INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1557 16TH STTELEPHONE:
(805) 534-9952
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Edwin InganTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Rankin arrived at 11:05 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator Edwin Ingan and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility has 3 resident bedrooms, and 2 bathrooms. Facility currently occupies 2 residents. LPA Rankin was authorized to enter and inspect facility. The facility has a smoke and carbon monoxide detector that was tested and working properly during visit. The fire extinguisher is scheduled to be reviewed. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in closet next to in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on October 28, 2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three.

Continued on 809-C
Kelly BurleyTELEPHONE: (805) 562-0413
Melisa RankinTELEPHONE: (805) 635-4718
DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE VII
FACILITY NUMBER: 405802134
VISIT DATE: 01/08/2025
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Staffing: The facility currently employes 2 full time staff due to lower census, with other staff from other facilities covering as needed, and one Administrator. Staff files were reviewed.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed two resident files for signed Admission Agreements, medical assessments, and appraisal & needs service plans, as well as other required documents and found all records complete.



Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The current emergency disaster forms were posted. Facility conducts quarterly drills, during which time they review the Disaster Plan to ensure staff have knowledge of their roles. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has two residents receiving hospice services.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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