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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802278
Report Date: 11/09/2022
Date Signed: 11/10/2022 04:32:59 AM

Document Has Been Signed on 11/10/2022 04:32 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 VFACILITY NUMBER:
405802278
ADMINISTRATOR:GREGORIO, ALBERTFACILITY TYPE:
740
ADDRESS:2117 DEL NORTETELEPHONE:
(805) 534-0808
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Faustina Jacinto/ Care GiverTIME COMPLETED:
10:30 AM
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At 9:45am on 11/09/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a resident transfer check. Resident was recently transferred from a different facility and in the best interest of the resident a transfer wiliness check was conducted. LPA met with Faustina Jacinto and announced the reason for the visit.

LPA met with caregiver and indicated that Resident 1 (R1) was doing fine and settled. R1 was recently at hospital for bladder infection and has been back at this facility for one day. R1 spent 5 days in the hospital being treated for bladder infection.

LPA met with R1, R1 required hearing aids to listen and converse. R1 stated to LPA that they like this facility much better than the one R1 was previously living. R1 stated that the caregivers take good care of R1 and R1 feels safe and is happy at this new facility.

LPA noted that R1 was cognitive, able to fully converse and express needs. R1 is non ambulatory, LPA noted that the facility and R1’s room appeared clean and in good repair. LPA noted, No issues observed.

Exit interview, report signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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