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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 10/14/2022
Date Signed: 10/15/2022 06:15:06 AM

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
10/11/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221011141312
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: 6DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Edwin Ingan/LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff left resident covered in ants
INVESTIGATION FINDINGS:
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 At 10:45am on 10/14/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct a complaint investigation to the allegation above. LPA met with Edwin Ingan and announced the reason for the visit. LPA conducted interviews with staff, residents and family members, made a cursory tour of the facility and requested documentation. LPA also issued findings to this complaint during this visit as follows:

As to the allegation of, "Staff left resident covered in ants." It was discovered through interviews and admission that on 10/11/2022 in the AM hours, there was an ant infestation on R1's person and in R1's room. R1 stated that there were ants on his mid-lower body on 10/11/2022 from approximately 4am - 8am. Additionally, this was noted by R1 as a single incident and the only time that it has happened and hasn't happened again. At 11:15am on 10/14/2022, interviews of staff S1, S2, and S3 stated that there were ants on R1's mid-lower body and from the floor to the bed that were discovered at approximately 7:30am on 10/11/2022. S2 stated that they immediately cleaned R1 while S2 conduced mitigation of ants. P1 arrived at the facility at 9:30am and was informed of the ants by R1. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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-20221011141312
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 I
FACILITY NUMBER: 405802274
VISIT DATE: 10/14/2022
NARRATIVE
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In interview with P1, P1 noted that they did not observe any ants on the body of R1, but were told by R1 that there were ants on R1's lower body and were cleaned that morning before P1 arrived. Based on the interviews and admission of the presents of ants by R1, S1, S2, S3 and P1 on R1's body was confirmed that R1's body was infested in ants for a period of at least 4 hours on the early morning of 10/11/2022, and therefore allegation of, "Staff left resident covered in ants." is substantiated at this time. This substantiation will result in a issuance of technical violation.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2