405802278-10-24-2024-29-AS-MRAN-DACS4L-20241024133254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802278
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:33:01 PM

Document Has Been Signed on 10/24/2024 01:33 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNRISE TERRACE RCFE V		FACILITY NUMBER:	405802278
ADMINISTRATOR:	GREGORIO, ALBERT		FACILITY TYPE:	740
ADDRESS:	2117 DEL NORTE		TELEPHONE:	(805) 534-0808
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 4	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Edwin Ingan		TIME COMPLETED:	01:45 PM

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	Licensing Program Analyst (LPA) Rankin arrived at 10:16 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Edwin Ingan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Physical Plant & Environmental Safety: The facility has 3 bedrooms and 2 bathrooms currently occupying 4 residents and employs 5 staff. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has a smoke alarm and discovered the carbon monoxide detector is not working properly, LPA will be sent image of new plugged in detector by close of business. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skids flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and front yard for client use with shade. The facility has telephone and internet service for resident use. The facility provides resident with a shared tablet for access internet. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE TERRACE RCFE V	FACILITY NUMBER: 405802278
	VISIT DATE: 10/24/2024

NARRATIVE

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Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 01/5/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has a battery backup solar system for emergencies.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility currently has 1 resident using oxygen. The facility currently has 1 resident on Home Health services. Home Health services records are kept on file. The facility has exiting door alarms for the safety of residents in care.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE TERRACE RCFE V	FACILITY NUMBER: 405802278
	VISIT DATE: 10/24/2024

NARRATIVE

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Operational Requirements: The facility has current liability insurance and expires on 10/28/2024. The facility is approved for a capacity of 6 non-ambulatory of which 1 may be bedridden, and Hospice approved for 3 residents.

Personnel Records & Training: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR for all 4 staff, all other record documentation was on file. Administrator certificate expires 12/26/24. LPA reviewed 4 staff training records for 2024 Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training, all staff completed required training.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for required records. All records are up to date, a TB record will be emailed to LPA for 1 resident who arrived from separate facility and results were not included. The Facility does not handle cash resources for the residents in care.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical & Dental: The facility has a locked medication cart in the dining room. Facility assists in locating transportation to medical and dental appointments when needed. A sampling of medication records was reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cart for all prescription and PRN medications with doctors’ orders. No medications labels were altered, and no medications were expired.

Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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