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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004715
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:19:30 PM


Document Has Been Signed on 04/26/2022 04:19 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: 6DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Administrator Rafael TeehankeeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Rafael Teehankee; and stated the purpose of this visit.

This facility is a two level structure and licensed for 6 non-ambulatory of which five may be bedridden and with hospice waiver for four. For this visit, there were four residents under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. There were six private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Paging system was observed to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 105 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non- perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self closing and self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Administrator's certificate is valid until January 27, 2023.

No citation was issued during this visit.

LPA Marin conducted an exit interview with AD R Teehankee and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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