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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002474
Report Date: 10/14/2024
Date Signed: 10/14/2024 12:37:45 PM

Document Has Been Signed on 10/14/2024 12:37 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LIFESTREAM HOME CARE FOR ELDERLYFACILITY NUMBER:
306002474
ADMINISTRATOR/
DIRECTOR:		FLORENCE TOLENTINOFACILITY TYPE:
740
ADDRESS:5165 SOMERSET STREETTELEPHONE:
(714) 228-9788
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Florence Tolentino - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Benjamin Aguila, Caregiver. Florence Tolentino, Administrator joined the inspection as well. LPA explained the purpose of the inspection.

The facility is one-story home with four resident bedrooms, three resident bathrooms, kitchen, dining room, living room, staff room, attached 2-car garage and backyard with pool. Pool is enclosed on all four sides. One side is enclosed by a brick wall separating the yard from a neighboring yard. The other three sides are enclosed by an iron fence with a gate. The gate to the pool remains locked and the pool is currently empty. Facility interior appears clean, safe and sanitary. LPA observed unused exercise/cleaning/renovating equipment in the backyard. A citation is being issued. LPA observed facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 9/12/2023 according to the attached service tag. A citation is being issued. Smoke/Carbon Monoxide detector were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet in the facility. Exit gates are unlocked. LPA observed exit gates to be unobstructed. Based on Record Review, LPA determined, the facility's Plan of Operation is not stored in the facility. A citation is being issued. LPA reviewed three resident files and three staff files. LPAs also reviewed medication for three residents. LPA interviewed one staff and one resident.



Based on today's inspection, three citations and four technical assistances are being issued. An exit interview was conducted and a copy of this report, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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 10/14/2024 12:37 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/14/2024 at 11:43 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: LIFESTREAM HOME CARE FOR ELDERLY
FACILITY NUMBER: 306002474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to the fire extinguisher service tag being dated 9/12/2023 which poses an immediate safety risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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4
Administrator stated they will get the fire extinguisher serviced by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2024 12:37 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/14/2024 at 11:56 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: LIFESTREAM HOME CARE FOR ELDERLY
FACILITY NUMBER: 306002474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to debris in the backyard which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Administrator stated they will remove unused grills, hardware, recreation items and other debris by the assigned POC due date.
Type B
Section Cited
CCR
87308(a)
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interivew and record review, the licensee did not comply with the section cited above due to the plan of operations not being maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Administrator stated they will have the plan of operations stored at the facility by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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