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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802274
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:53:39 PM

Document Has Been Signed on 09/28/2022 02:53 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 6DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Edwin IganTIME COMPLETED:
12:00 PM
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 At 10:00am on 09/28/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual infection control inspection. LPA was met at the door by Licensee Edwin Ingan. LPA announced who he was and the reason for the visit.

At 10:15am Licensee and LPA conducted a facility tour. This is a 5 bedroom 2 bathroom, kitchen, living room and backyard outdoor area with shading for residents in care. LPA observed 2 days of perishable and 7 days of nonperishable foods. LPA observed all fire extinguishers to be in compliance with regulations. LPA observed all fire detractors and carbon monoxide detectors to be in working order. LPA noted that the water from faucets from the kitchen and bathroom one to be with in regulation range of 95*f to 120*f. LPA did not observe and hazards or obvious dangers to residents in care. LPA observed a adequate supply of PPE at the facility and noted that facility has a universal mass supply for all five facilities under this Licensee. LPA observed the facility to be clean and organized and every appliance to be in good working order.

Licensee and LPA conducted the infection control module of the annual inspection tool. LPA noted that all questions were answered in the affirmative "Yes: and there were no deficiencies cited on this annual inspection.

Exit interview, report singed and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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