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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004798
Report Date: 07/02/2024
Date Signed: 07/02/2024 12:11:24 PM

Document Has Been Signed on 07/02/2024 12:11 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:AMANA SENIOR LIVINGFACILITY NUMBER:
306004798
ADMINISTRATOR/
DIRECTOR:		RAFAEL/JOSEPHINE TEEHANKEEFACILITY TYPE:
740
ADDRESS:26232 AVENIDA CALIDADTELEPHONE:
(949) 616-9380
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Josie Teehankee, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after explaining the purpose of the visit. Facility administrator Josephine Teehankee was notified by telephone and arrived shortly afterwards to assist.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with six private bedrooms and one staff room in addition to the facility's common living areas and two full bathrooms, including one en-suite. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. One resident awaiting hospice admission is observed to have a bed equipped with full rails. LPA provided a consultation on hospice requirements for full bed rails and observed staff replacing the postural supports with half rails during the visit. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents admitted to the facility with one resident receiving hospice care and another one pending admission. 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. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire drills are conducted quarterly. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present are 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. LPA reviewed five resident files, two hospice files and four staff files.

Based on the observations made during today’s inspection, one type B deficiency are being cited per Title 22 Division 6 of the California Code of Regulations along with one advisory note provided. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 07/02/2024 12:11 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/02/2024 at 11:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMANA SENIOR LIVING
FACILITY NUMBER: 306004798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the facility visit and records reviewed, the licensee did not comply with the section cited above as one resident's bed was observed to be equipped with full-length bed rails even though the resident was not yet admitted onto hospice. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Full rails were replaced by half rails by facility staff pending an updated physician order after the admission onto hospice is valid.
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 Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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