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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004715
Report Date: 07/12/2022
Date Signed: 07/12/2022 10:26:56 AM

Document Has Been Signed on 07/12/2022 10:26 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: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:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Josie Teehankee TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced case management visit to this facility. LPA met with Administrator Josie Teehankee and stated the purpose of this report.

The purpose of this visit was to continue the case management initiated last 7/8/2022.

For this visit, LPA toured the facility, did a file review and interviews.

On this visit, no citation was issued at this time.

LPA Marin conducted an exit interview with AD Teehankee; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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