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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802274
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:17:00 PM


Document Has Been Signed on 10/09/2023 12:17 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:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Licenee / Edwin InganTIME COMPLETED:
12:15 PM
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 At 10:00am on 10/09/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual inspection. LPA met with Licensee Edwin Ingan, announced who he was and the reason for the visit.
At 11:15am 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 detector to be in working order. LPA noted that all rooms have proper lighting, linin, and storage meeting CCLD regulations. Licensee and LPA conducted a sample medication audit and found centrally stored medication log to be accurate. LPA noted that medications are locked in a medication cabinet in the living room. LPA noted that resident files secured in a cabinet in the living room and staff are secured at a central office as licences has 4 other facilities. 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 a full review of the annual control tools kit, including all modules. LPA noted one technical violation of not documenting last emergency drill, Licensee stated that a fire drill last took place in July of 2023, and a earthquake drill is scheduled to take place in October of 2023 and will document that drill and email LPA of the documentation of that drill. LPA did not note any other violations or citations during this annual and the full annual care tools review.
Exit interview, report read and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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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