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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802134
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:39:47 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
03/23/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220323143945
FACILITY NAME:SUNRISE TERRACE RCFE VIIFACILITY NUMBER:
405802134
ADMINISTRATOR:INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1557 16TH STTELEPHONE:
(805) 534-9952
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Edwin Ingan, AdmimistratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are not following masking requirements
INVESTIGATION FINDINGS:
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Licensing Program Anaylst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA met with Administrator Edwin Ingan and explained the purpose of the visit.
LPA Requested a Staff Roster and Resident Roster. Interviewed Staff 1 (S1) and Staff 2 (S2).
On the allegation:Staff are not following masking requirements. LPA interviewed crediable witness (W1) which revealed that W1 visited the facility on 03/16/2022 and upon entry to the facility two staff were present and one staff was sitting at the dining room table with residents and the staff was not wearing a mask. Based on the evidence the allegation is deemed Substantiated at this time.
Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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-20220323143945
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 VII
FACILITY NUMBER: 405802134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in all Facilities:..To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Provide training records with all
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Based on interviews the licensee did not ensure all staff were wearing face coverings in the facility which poses an immediate health, safety and personal rights risk to residents in care.
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staff signatures to CCL by 03/28/2022.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2