306004798-10-4-2021-22-AS-LADS-C7JSDB-20211006134651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004798
Report Date: 10/04/2021
Date Signed: 10/04/2021 11:16:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2021 and conducted by Evaluator Albert Marin

COMPLAINT CONTROL NUMBER: 22-AS-20210930162454

FACILITY NAME:	AMANA SENIOR LIVING		FACILITY NUMBER:	306004798
ADMINISTRATOR:	RAFAEL/JOSEPHINE TEEHANKEE		FACILITY TYPE:	740
ADDRESS:	26232 AVENIDA CALIDAD		TELEPHONE:	(949) 616-9380
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	10/04/2021
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Administrator Josephine Teehankee		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an unexplained fracture while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPA met with Administrator (AD) Josephine Teehankee; and stated the purpose of the visit and the allegation indicated above.

LPA Marin toured the interior and exterior portions of the facility. LPA observed six residents in care and two staff members on the floor. LPA interviewed AD Teehankee; and review resident files. Based on file review and interviews, Resident 7 had never been a resident of this facility. Thus the allegation is unfounded.

This agency has investigated the complaint alleging that resident sustained an unexplained fracture while in care . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

LPA Marin conducted an exit interview with AD Teehankee. AD gave permission for staff to sign and receive the report. LPA left copy of this report in the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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