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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004710
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:58:46 PM

Document Has Been Signed on 12/09/2024 04:58 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:ALLIANCE SENIOR LIVING 2FACILITY NUMBER:
306004710
ADMINISTRATOR/
DIRECTOR:		RAFAEL TEEHANKEEFACILITY TYPE:
740
ADDRESS:25511 CLASSIC DRIVETELEPHONE:
(949) 305-1044
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Josie Tehankee, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 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 introducing himself and stating the purpose of the visit. Administrator Josie Tehankee was notified of the visit via telephone and arrived later to assist.

LPA accompanied by facility staff conducted a tour of the physical plant and observed the following: the facility is a one-story home with an attached garage. The facility has a total of four single and one shared bedrooms. There are two shared bathrooms and one en-suite bathroom in the facility. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was measured at 121.3F and 120.5F in two bathrooms used for personal hygiene. Technical Violation Advisory Note provided. LPA observed all beds have linen and blankets. There are half rails used for postural supports for two residents and full rails for a third. Physician orders for two residents reviewed and hospice plan of care reviewed.

There are currently five residents admitted to the facility. One resident is receiving hospice care out of a waiver capacity of two possible hospice residents. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills have been conducted quarterly in 2024. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been purchased in 2024 as demonstrated by the receipt on display.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress on both sides are free of obstructions.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ALLIANCE SENIOR LIVING 2
FACILITY NUMBER: 306004710
VISIT DATE: 12/09/2024
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CONTINUED FROM FORM LIC809
Cleaning products are observed to placed in a locked cabinet under the kitchen sink. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed five resident files along with three staff files. Resident records include all necessary components. All staff members present are confirmed to be cleared and associated with this particular licensed location. Training verified to be up to date. CPR training documentation on file. Health screenings are on file for staff members reviewed.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One Technical Violation Advisory Note issued regarding the water temperature.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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