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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802275
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:31:43 PM


Document Has Been Signed on 10/09/2023 04:31 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 IIIFACILITY NUMBER:
405802275
ADMINISTRATOR:INGAN, ZENAIDAFACILITY TYPE:
740
ADDRESS:1015 SAN ADRIANO STREETTELEPHONE:
(805) 544-2883
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 6DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Licensee Edwin InganTIME COMPLETED:
03:30 PM
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 At 12:20pm on 10/09/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection for this facility. LPA met with Licensee Edwin Ingan, announced who he was and the reason for the visit.

At 12:45pm Licensee and LPA conducted a physical tour of the facility. LPA noted that this is a 3 bedroom, all rooms are double resident occupancy and two bathrooms, bathroom one is in a master bedroom and the other bathroom is in the hallway. Both bathrooms have secure handicap handrails, nonskid mats, properly functioning appliances, stocked, liquid soap and paper towels are also present in both bathrooms. All bedrooms have enough storage space according to regulations, lights are working and beds have linins that me regulation requirements. LPA noted that each bedroom has a wired smoke detector and smoke detectors in common areas of home, which are all hardwired. There is working carbon monoxide detector in the hallway. LPA observed fire extinguishers in the green and tagged current in within last 6 months. LPA noted that all exits are free and clear of obstructions. LPA observed the outside of the facility, with a table and umbrella for residents outside in the shade. LPA observed at least 2 days of perishable and seven days of non-perishable foods on hand. LPA noted that resident files, staff files and medications are locked in a cabinet in the TV console in the living room area. LPA conducted a sample medication inspection and found no regulation violations. LPA reviewed staff and resident files, LPA also reviewed staff training records and found no regulation violations.

At 1:35pm, Licensee and LPA conducted the review of each module of the care tools inspection tool. LPA noted that there were no violations of during the review of all of the care tool modules. At this time LPA found no violations of care tool module and physical inspection of the facility at this time.

Exit interview, report read, report singed, 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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