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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004715
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:07:34 PM

Document Has Been Signed on 07/08/2022 01:07 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:ALLIANCE SENIOR LIVING 3FACILITY NUMBER:
306004715
ADMINISTRATOR:RAFAEL TEEHANKEEFACILITY TYPE:
740
ADDRESS:26871 LA SIERRATELEPHONE:
(949) 305-9024
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
07/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Administrator Josie TeehankeeTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Albert Marin and Celine De Perio conducted an unannounced case management visit to this facility. LPAs met with Administrator Josie Teehankee and stated the purpose of this report.

On July 7, 2022, The Community Care Licensing Division (CCLD) Orange Office received an incident from the facility stating that Resident 1 had an incident in the facility. Emergency Medical Services (EMS) was activated. EMS came and attempted to resuscitate R1 . R1 passed away in the facility. Responsible party and hospice agency were notified.

On this visit, LPAs Marin and De Perio toured the facility; and observed five residents in care and three staff members on the floor. LPAs toured the facility and inspected the all resident's rooms and common areas. LPAs did file review and random interviews. LPA requested to take the facility files that included but not limited to admission agreement, physician report, needs and services plan, centrally stored medication log and hospice notes.

Due to time constraints, this visit will be completed at a later time.

No citation was issued on this visit.

LPAs Marin and De Perio conducted an exit interview with AD Teehankee; and copy of this report was left on the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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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