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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005767
Report Date: 05/05/2022
Date Signed: 05/05/2022 10:30:41 AM

Document Has Been Signed on 05/05/2022 10:30 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:TRANQUILITY SENIOR LIVINGFACILITY NUMBER:
306005767
ADMINISTRATOR:BRYANT II, LANCEFACILITY TYPE:
740
ADDRESS:285 E 22ND STTELEPHONE:
9493312744
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 6DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Josie Teehankee - Asst. AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Tranquility Senior Living. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Camille Flores. Caregiver Brian Rillon was also present. Assistant Administrator (AA) Josie Teehankee arrived later to assist with the visit. The facility is licensed for 6 bedridden residents. The facility also has a Hospice waiver for 2 residents. There are currently 6 residents living in the facility. LPA Velazquez was informed that 3 residents are currently receiving hospice services. The last emergency disaster drill was conducted on April 30, 2021.


At 9:17 AM LPA Velazquez conducted a tour of the physical plant along with AA Teehankee. The 1 story home consists of 6 resident bedrooms each with their own bathrooms. There are 2 staff bedrooms with 1 staff bathroom. The facility also has a living room, dining area, laundry room, office, and kitchen. The 6 residents in the facility appeared well-groomed and well cared-for. LPA Velazquez observed the Complaint Poster in the entry area was not in the correct size and advised AA Teehankee to obtain one in the correct size of 20" by 26". The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 118.7 degrees Fahrenheit in the first bathroom, at 119.4 degrees Fahrenheit in the second bathroom, at 118.4 degrees Fahrenheit in the third bathroom, at 116.7 Fahrenheit in the fourth bathroom, at 117.1 degrees Fahrenheit in the fifth bathroom, at 120.3 degrees Fahrenheit in the sixth bathroom, and at 118.5 degrees Fahrenheit in the hall bathroom all of which AA Teehankee verified.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TRANQUILITY SENIOR LIVING
FACILITY NUMBER: 306005767
VISIT DATE: 05/05/2022
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LPA Velazquez inspected the kitchen along with AA Teehankee. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition.

LPA Velazquez along with AA Teehankee toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and 1 of the two exit gates had a self-closing latch which AA Teehankee verified. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. During the visit LPA Velazquez was informed the facility has 3 residents currently receiving hospice services. The facility is operating beyond the conditions and limitations specified on the license which AA Teehankee verified. LPA Velazquez printed and reviewed the following Title 22 Regulation Section 87632 Hospice Care Waiver and Section 87633 Hospice Care of Terminally Ill Residents. AA Teehankee acknowledged receiving copies of said regulations and will submit a letter to Licensing requesting an increase in the facility's hospice waiver.



There were no deficiencies issued during this 1 Year inspection. An exit interview was conducted with Assistant Administrator Josie Teehankee and a copy of this report along with the LIC 9102s were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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