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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802274
Report Date: 08/31/2021
Date Signed: 08/31/2021 11:55:16 AM

Document Has Been Signed on 08/31/2021 11:55 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 IFACILITY NUMBER:
405802274
ADMINISTRATOR:INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1135 OCEANAIRE DRIVETELEPHONE:
(805) 544-0982
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Edwin Ingan/AdministratorTIME COMPLETED:
12:30 PM
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At 8:40am, Licensing Program Analyst (LPA) Mark Jeffries contacted the facility by phone to conduct the COVID-19 screening. No staff or residents presented any symptoms or had a positive status of COVID-19. At 8:50am LPA arrived at the facility and announced the reason for the visit is a Infection Control Annual Inspection. LPA met with Administrator Edwin Ingan.
At 9:15am Administrator and LPA conducted a tour of the facility. A cursory tour of the facility consisted of four bedrooms two bath rooms, one staff room a split living room, kitchen and dining room. the medication cart is secured and locked in the split of the living room. There is a laundry room located behind the garage with access from the residents hallway. LPA observed 2 days perishable and 7 days of nonperishable foods. All fire extinguishers in green level working order. All bed rooms has proper linin, lighting and storage space per regulations. LPA observed all restrooms had properly functioning commodes and all hand bars were firmly secured to the walls, each shower had non-slip mats located in the shower stalls. LPA and Administrator also toured the outside of the facility, all windows had working screens and no visible hazards were observed. LPA was able to auditory observed the delayed egress system working on each exit door in the facility. LPA did not observe any visual hazard on this cursory inspection of the facility from the outside to the inside. At 10:00am LPA and administrator conducted the infection control module of the inspection. LPA noted that entry screening procedures were not practiced on a consistent basis due to LPA not being screened on this day. LPA issued a Technical Advisory and had Administrator conduct staff training on entry screening procedures during the inspection visit.

Exit interview conducted, technical advisory conducted, report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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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