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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004798
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:29:48 AM

Document Has Been Signed on 04/28/2022 10:29 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: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:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Administrator (AD) Josie TeehankeeTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct investigation for an incident. LPA met with Administrator (AD) Josie Teehankee; and stated the purpose of this visit.

On April 13, 2022, Community Care Licensing Division (CCLD) Orange Office received a report from the facility indicating that on April 13, 2022, Staff 1 had a verbal altercation with a resident in the facility. Facility immediately followed up the case; and on the same day, terminated employment of Staff 1 in this facility and all its affiliates.

For this visit, LPA observed six residents in care and three staff members on the floor. LPA toured the common areas and residents rooms. After the tour, LPA conducted interviews; and file review.

No citation was issued during this visit.

LPA Marin conducted an exit interview with AD J. Teehankee; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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