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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:44:05 PM

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
07/10/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240710085719
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:
07/11/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator - Edwin InganTIME COMPLETED:
02:46 PM
ALLEGATION(S):
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Staff did not properly secure the resident's medications.
INVESTIGATION FINDINGS:
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 At 12:40pm on 07/11/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to investigate the allegation to this complaint. LPA met with Administrator Edwin Ingan announce who he is and the reason for the visit. LPA conducted interviews.
As to the allegation of, "Staff did not properly secure the resident's medication,' It was alleged that on 07/09/2024 at 1:21pm a reliable witness (person with license or credentials indicating expertise training) observed the medication cart in the living room with keys in cart and two residents sitting next to cart with no staff present. It was discovered in LPA Jeffries interviews on 07/11/2024 of Staff 1 (S1) who was working on 07/09/2024 at the time when medication cart was left unattended. S1 stated that they were conducting medication pass when S1 was called to assist another staff and visiting nurse to resident room and left key in medication cart. There were two Residents in the same room as the medication cart with keys and no staff present. Based on admission, and reliable witness there is enough evidence at this time to support the allegation of, "Staff did not properly secure the resident's medications." and is substantiated at this time.
Exit interview, report read, appeal rights and report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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 2
Control Number 29-AS-20240710085719
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: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2024
Section Cited
CCR
87465(a)(1)
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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 with keys when
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 Administrator agreed to change medication distribution procedure by relocateing the mediation cabinet to a double secure location in the facility.
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staff unsupervised with resident present on 07/1/2024, which poses an imminent danger 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
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