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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802274
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:35:33 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
07/02/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240702091140
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:
07/03/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff spoke another language in front of residents in care.
INVESTIGATION FINDINGS:
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 At 11:00am on 07/03/2024, Licensing Program Analyst (LPA) Jeffries arrive unannounced to conduct the initial investigation to the allegation to this complaint. LPA met with Administrator, Edwin Ingan, announced who he is, and the reason for the visit.
LPA conducted interviews, reviewed documentation and issued final findings on this visit.

As to the allegation of, “Staff spoke another language in front of residents in care.” On 07/01/2024, at approximately 12:30pm, it was observed by a reliable witness (person with license or credentials indicating expertise training) that the Facility Administrator, Edwin Ingan, and Direct Care Staff (S1) were conversating in Tagalog language while residents in care were in the close proximity. It was discovered through interviews of Administrator and S1 on 07/03/2024, that both admit to communicating in Tagalog in front of Residents in care through kitchen opening. Both stated that none of the residents in care speak or fully understands the language of Tagalog.

CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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 3
Control Number 29-AS-20240702091140
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: 07/03/2024
NARRATIVE
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On 07/03/2024, LPA Jeffries reviewed 4 of 4 Residents’ LIC602’s (Physicians Reports) indicating that 3 of 4 Residents have cognitive impairment or Dementia. LPA noted that English is the primary language of 4 of 4 residents. On 06/03/2024, S1 was observed by a reliable witness speaking Tagalog while providing direct care of resident and subsequently the facility was citied for personal rights violation on 06/06/2024 for that violation. The Administrator conducted training of which verification of personal rights training was sent by email to LPA on 06/11/2024. This is the second violation of resident’s personal rights, by speaking a forging language in the direct presence of residents in care who have cognitive impairment to dementia diagnosis which does not accord residents dignity in their relationships with staff. At this time there is enough evidence to support the allegation of, “Staff spoke another language in front of residents in care.” and is substantiated at this time.
Exit interview, report read, citation and civil penalty issued, report and appeal rights provide.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240702091140
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights ... (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee will conduct a 1 hour personal rights training for all staff associated to this facility. Administrator will show who the training was by, the staff that attended, the name of the class and the hours the class was conducted and the dates staff attendance. Administrator will email LPA the above information.
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This requirement was not met by evidence of Staff speaking language which resident did not speak or understand while in direct proximity on 07/01/2024. which poses a potential risk to resident in care.
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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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3