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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004277
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:00:05 PM


Document Has Been Signed on 11/09/2022 04:00 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VALARTA LANE SENIOR LIVINGFACILITY NUMBER:
306004277
ADMINISTRATOR:RAFAEL&JOSEPHINE TEHANKEEFACILITY TYPE:
740
ADDRESS:23631 VALARTA LANETELEPHONE:
(949) 305-2365
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Rafael TeehankeeTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Valarta Lane Senior Living to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 2:51pm, LPA Cho was greeted and granted entry by Caregiver Roselle Abud. Also present were Caregivers Aaron Guevarra and Arnel Claro. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station with a thermometer. Facility has discontinued COVID-19 screening and documenting temperatures of visitors on the sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) was observed in the size of 11"x14" which did not meet the Department size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which two are receiving hospice care. The Administrator's Certificate for Rafael Teehankee expires on 01/27/2023.

At 2:59pm, LPA Cho conducted a tour of the physical plant with Caregiver Roselle Abud. There are a total of six resident bedrooms and seven resident bathrooms. There is a private staff bedroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 109.2 degrees Fahrenheit in Bathroom #1, 111.0 degrees Fahrenheit in Bathroom #2, 115.1 degrees Fahrenheit in Bathroom #3, 114.4 degrees Fahrenheit in Bathroom #4, 114.9 degrees Fahrenheit in Bathroom #5, 115.3 degrees Fahrenheit in Bathroom #6, and 115.5 degrees Fahrenheit in Bathroom #7. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and purchased on 11/09/2022.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VALARTA LANE SENIOR LIVING
FACILITY NUMBER: 306004277
VISIT DATE: 11/09/2022
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Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. One of two exit gates were not self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Administrator Rafael Teehankee, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
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
LIC809 (FAS) - (06/04)
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