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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004715
Report Date: 04/30/2024
Date Signed: 04/30/2024 12:43:11 PM


Document Has Been Signed on 04/30/2024 12:43 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
ORANGE COUNTY RO, 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:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rafael Tehankee, AdministratorTIME COMPLETED:
12:45 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Rose-Mary Ruppert made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the reason of the visit. Administrator Rafael Tehankee was notified of the visit and arrived later to assist.

During the inspection, LPA and caregivers conducted a tour of the physical plant and observed the following: The facility is a two-story home with six private resident bedrooms and two shared bathrooms. Staff living quarters are located on the second floor and the access door to the stairway is kept locked. All resident bedrooms had the required furnishings. LPAs observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents in care at the facility, none of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. The facility is also equipped with a sprinkler system. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPAs reviewed five resident files and eight staff files. The two staff members on duty were interviewed along with two residents.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 12:43 PM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ALLIANCE SENIOR LIVING 3
FACILITY NUMBER: 306004715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above as one staff member file was observed to not include a health screening form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee will obtain a valid health screening for the staff member and transmit a copy to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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