306004410-2-14-2024-22-AS-KLYN-D2F22K-20240213160051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004410
Report Date: 02/13/2024
Date Signed: 02/14/2024 07:29:36 AM

Document Has Been Signed on 02/14/2024 07:29 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PRIORITY CARE SENIOR LIVING		FACILITY NUMBER:	306004410
ADMINISTRATOR:	RAFAEL/JOSEPHINE TEEHANKEE		FACILITY TYPE:	740
ADDRESS:	23762 SAN ESTEBAN		TELEPHONE:	(949) 305-9870
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Josephine Teehankee		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Priority Care Senior Living. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Jennii Burba. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 6 residents. There are 2 residents on hospice during today's visit. Josephine Teehankee has an Administrator Certificate expiring on 11/19/2024. Administrator Josephine Teehankee arrived during the visit. LPA Lyman along with Administrator Josephine Teehankee toured the facility at 1:31 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of six resident bedrooms, five resident bathrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.7 and 116.9 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. The entry door into the garage is alarmed. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. At 1:50 PM, LPA observed the fire extinguisher in kitchen needs to be charged. Receipt attached to the extinguisher indicates it was charged in August 2023. Kitchen appliances are operational during today's visit. LPA toured the outside grounds at 2:00 PM and there is ample shaded seating for residents. LPA observed the exit gate does not easily open and there are discarded items in the yard. CONTINUED ON LIC 809C DATED 2/23/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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: PRIORITY CARE SENIOR LIVING	FACILITY NUMBER: 306004410
	VISIT DATE: 02/13/2024

NARRATIVE

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LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 09/14/2023. Facility provides activities in the form of games and exercise. At 2:20 PM, LPA reviewed six resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 3:00 PM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/14/2024 07:29 AM - It Cannot Be Edited

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: PRIORITY CARE SENIOR LIVING	FACILITY NUMBER: 306004410
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed fire extinguisher is in need of being charged, exit gate is in need of repair and there are discarded items in the yard. This poses a potential health and safety risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Licensee agrees to address all noted items and forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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