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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802275
Report Date: 09/09/2021
Date Signed: 10/27/2021 04:58:01 PM

Document Has Been Signed on 10/27/2021 04:58 PM - 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 IIIFACILITY NUMBER:
405802275
ADMINISTRATOR:INGAN, ZENAIDAFACILITY TYPE:
740
ADDRESS:1015 SAN ADRIANO STREETTELEPHONE:
(805) 544-2883
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 0DATE:
09/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Edwin Ingan/LicenseeTIME COMPLETED:
11:08 AM
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At 8:00am on 09/09/2021, Licensing Program Analyst (LPA) Mark Jeffries contacted Licensee Edwin Ingan py phone to meet at facility to conduct a visual inspection of closure. Licensee arrived at the facility at 9:07am. LPA and Licensee toured the entire facility and facility grounds. LPA did not observe any furnature and did observe a for sale sign on the front property of the facility. Licensee stated that the last resident left in April of 2021 and that they have not had any new residents after the last resident in April. License stated that he had notified the previous LPA of the closures. LPA was able to verify closure notice to prior LPA by LIC812 on 05/05/2021 for facility #405802276.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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