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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802272
Report Date: 11/09/2022
Date Signed: 11/10/2022 04:36:20 AM

Document Has Been Signed on 11/10/2022 04:36 AM - 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 IIFACILITY NUMBER:
405802272
ADMINISTRATOR:SADORRA, HECTORFACILITY TYPE:
740
ADDRESS:1338 ROYAL WAYTELEPHONE:
(805) 541-1843
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 4DATE:
11/09/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Edwin Ingan/LicenseeTIME COMPLETED:
02:03 PM
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At 11:20am on 11/09/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a resident transfer check. Resident was recently transferred from a different facility and in the best interest of the resident a transfer wiliness check was conducted. LPA met with Edwin Ingan, License and announced the reason for the visit.

LPA met with Licensee and indicated that Resident 1 (R1) was doing fine and settled. Licensee stated that R1 is non ambulatory, however R1 was up and out of bed in living room every day that they have been here at the new facility.

R1 was able to converse with LPA, R1 was in good spirts and talked about their childhood and family. R1 was observed to be in good physical health and was lively conversationalist, however some minor cognitive reasoning skills were apparent.

LPA noted that the facility was lean and in good repair.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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