<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 06/06/2024
Date Signed: 06/06/2024 10:19:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240604112518
FACILITY NAME:SUNRISE TERRACE RCFE IFACILITY NUMBER:
405802274
ADMINISTRATOR:INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1135 OCEANAIRE DRIVETELEPHONE:
(805) 544-0982
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 4DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Edwin Ingan - Licnesee TIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly secure the resident's medications.
Staff spoke another language in front of residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 At 9:44am on 06/06/2024, LPA Jeffries arrived at the facility unannounced to conduct the initial investigation visit to the allegation to this complaint. LPA met with Licensee Edwin Ingan announced who he is and the reason for the visit. LPA conducted interviews, requested documentation, determined final findings, and issued the final findings below.

As to the allegation of, “Staff did not properly secure the resident's medications.” It was alleged that on 06/03/2024 the facilities medication cart was unlocked and unattended in the presence of residents while caregivers were providing care in separate resident room. I was discovered through interviews, documentation, and admission that on 06/03/2024 witness 1 (W1) who is a Reliable Source (person with license or credentials indicating expertise training) arrived at the facility, knocked on the facility front door to no answer, then entered through a side door, and discovered medication cart with unlocked drawer in the facility primary living room, with Resident 1 (R1) and R2 both sitting in same room as the unlocked medication cart. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240604112518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
VISIT DATE: 06/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 On 06/06/2024, LPA conducted interviews with Staff 1 (S1) and S2 who stated that the medication cart drawer was unlocked during the time of W1’s visit to the facility on 06/03/2024. S1 and S2 also stated that during the time of W1 visit S1 and S2 were the only staff on duty. On 06/06/2024, LPA conducted interviews with Resident 1 (R1) and R2, who stated that they were in the living room area every day for the past week. At this time there is enough evidence that, “Staff did not properly secure the resident’s medication.” and is substantiated at this time.
As to the allegation of, “Staff spoke another language in front of resident.” It was alleged that on 06/03/2024 W1 observed S1 and S2 speaking in Tagalog while providing hands on direct care to resident in care whose primary language is English and does not speak or understand Tagalog. I was discovered through interviews, documentation, and admission that on 06/03/2024 W1 who is a Reliable Source (person with license or credentials indicating expertise training) arrived at the facility, knocked on the facility front door to no answer, then entered through a side door and discovered that S1 and S2 were providing direct, hands-on care to R3, in R3’s room. On 06/05/2024, LPA interviewed W1, who stated that S1 and S2 were speaking in Tagalog while both were standing over, hands on, direct care to R3. W1 also stated that over the past 24 months W1 has spoken to both S1, S2 and facility Administrator a minimum of 4 separate visits to the facility on speaking resident primary language while providing care as a personal rights violation to residents in care address treating residents in care with dignity. On 06/05/2024, LPA conducted interviews with S1 and S2 who both admitted to speaking Tagalog while providing direct care to R3 on 06/03/2024. S1 and S2 both acknowledged that R3 does not speak or understand Tagalog. LPA noted that on 08/11/2023 and 05/09/2023 LPA spoke with Administrator, S2, and S3 on addressing the residents’ personal rights concerns with treating residents with dignity by speaking resident primary language while in the presents or direct care of a resident, and highlighting the importance of residents with cognitive decline, dementia, and Alzheimer’s in this regard. Based on interviews, observations and admission, there is enough evidence to support the allegation of, “Staff spoke another language in front of resident.” and is substantiated at this time.

Exit interview, report read, citations issued, appeal rights, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240604112518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87465(1)(a)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (1) Medications shall be centrally stored... (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees ... This requirement was not met by evidence of Medication Cart found to be unlocked and
1
2
3
4
5
6
7
Licensee will conduct medication retraining for all staff at this facility. And will provided direct medication supersession for the next 60 days. Administrator will check in with LPA on 06/07/2024 and 07/07/224 and 08/07/2024 as to medication security.
8
9
10
11
12
13
14
staff unsupervised with resident present on 06/03/2024, which poses an imminent danger to residents in care.
8
9
10
11
12
13
14
Type B
06/20/2024
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
87468.1 Personal Rights ... (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of Staff speaking
1
2
3
4
5
6
7
Licensee will prived Personal Rights training for S1 and S2 by 06/20/2024 and submit proof to LPA my email or fax.
8
9
10
11
12
13
14
a language which residents did not speak or understand while providing direct care on 06/03/2024. Which poses a potential risk to resident in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3