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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004798
Report Date: 01/12/2021
Date Signed: 01/12/2021 03:57:21 PM

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:AMANA SENIOR LIVINGFACILITY NUMBER:
306004798
ADMINISTRATOR:RAFAEL/JOSEPHINE TEEHANKEEFACILITY TYPE:
740
ADDRESS:26232 AVENIDA CALIDADTELEPHONE:
(949) 616-9380
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
01/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Administrator Josie TeehankeeTIME COMPLETED:
03:58 PM
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As precautionary measures during Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made a unannounced televisit to the facility. LPA spoke with Administrator (AD) Josie Teehankee; and stated the purpose of the televisit.

Assisted by AD J. Teehankee, LPA Marin conducted a virtual tour of the interior and exterior portions of the facility. LPA observed five residents in care and two staff members on duty - Staff 1 and Staff 2. LPA did not observe any other individual inside or outside the facility. Staff 1 and Staff 2 denied that Applicant 1 had ever work in the facility.

An exit phone interview with AD J. Teehankee. LPA will provide copy of this report via email; and as agreed AD J. Teehankee will acknowledge its receipt.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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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