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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802274
Report Date: 03/11/2025
Date Signed: 03/11/2025 08:58:14 AM

Document Has Been Signed on 03/11/2025 08:58 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/
DIRECTOR:		INGAN, EDWINFACILITY TYPE:
740
ADDRESS:1135 OCEANAIRE DRIVETELEPHONE:
(805) 544-0982
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:58 AM
MET WITH:Administrator, Edwin InganTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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 At 7:45am on 03/11/2025, Licensing Program Analysts (LPAs) Jeffries and Haner-Tomasko arrived to the facility unannounced to conduct a Case Management visit and a subsequent complaint on a separate report. LPAs met with Administrator, Edwin Ingan, announced who they are and the reason for the visit.

As a result of the subsequent complaint investigation conducted on this visit, it was discovered that the facility has failed to repot any changes in conditions with Serious Incident Reports (SIR) of the residents or any Deaths Reports that have occurred or Hospice Notifications. LPA reviewed both the Serious Incident Report file, Death Reports, and Hospice Notifications (Efax for review for 405802274) and found zero SIR's, zero Death reports, and zero Hospice Notifications. LAP's reviewed Resident 1 (R1) Hospital visit discharge paper work dated 01/21/2025. This hospitalization was not reported to Community Care Licensing by the facility or Administrator. This is a failure to report to licensing and a citation for Reporting Requirements [87211(1)(a)] is issued from this report. Licensee stated that they have had deaths and hospice residence in the past 3 years at this facility. Administrator stated that he had faxed report to LPA Rankin. On 03/11/2025 LPA Jeffries confirmed by phone call that all reports Administrator submitted were filed, LPA Jeffries noted zero reports file for this facility.

Report read, citation issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 08:58 AM - It Cannot Be Edited


Created By: Mark Jeffries On 03/11/2025 at 08:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE TERRACE RCFE I
FACILITY NUMBER: 405802274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2025
Section Cited
CCR
87211(a)(1)

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Reporting Requirements 87211(a)(1) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident
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Administrator will train all Administrators and staff of reporting and will provide evidence to LPA Jeffries by email on or before 03/25/20.
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 within seven days of the occurrence of any of the events specified... if any; and disposition of the case. This requiorment was not met by evidence of failure to report R1 hospitalization and admission of Administrator which put residents in potential danger.
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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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