306004798-5-16-2023-22-AS-SSAS-CS4V9Y-20230523161505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004798
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:35:10 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
05/09/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230509094358

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:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Josie Teehankee, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff accidentally served toxics to facility residents, resulting in hospitalization

INVESTIGATION FINDINGS:

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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 investigating the allegation listed above. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Josie Tehankee was present during the visit as she was supervising a tour for a prospective resident's family.

While at the facility, LPA conducted interviews with two staff members along with one witness. During the investigation, it was established that the incident of intoxication to individuals in care was reported at the wrong address and actually occurred at a facility observed to be located next door to the present facility at 26242 Avenida Calidad. During the visit, the facility was confirmed to not be licensed through the Department.

The allegation is therefore Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. An exit interview was conducted and a copy of this report was provided to the facility representative.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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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