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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004798
Report Date: 07/16/2021
Date Signed: 07/16/2021 02:01:50 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: 6DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Administrator (AD) Josie TeehankeeTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Josephine “Josie” Teehankee and stated the purpose of this visit.

The facility is a one-level structure and licensed for capacity of six non-ambulatory of which one may be bedridden and with hospice waiver for four. For this visit, there was no resident under hospice care.

About 12:48 PM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA observed six clients in care, and three staff members on the floor. LPA toured the interior and exterior portions of the facility. There were six private rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair provided with grab bars and non-skid floor mats and hot water was measured at 108 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion. patio furniture were observed in to be in good repair, and grounds were free of tripping hazards. Side exit doors were self closing and self latching.

LPA reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD J. Teehankee. LPA left copy of this report in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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