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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002474
Report Date: 11/15/2024
Date Signed: 11/15/2024 09:08:35 AM

Document Has Been Signed on 11/15/2024 09:08 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
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: 4DATE:
11/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:Florence Tolentino - Administrator TIME VISIT/
INSPECTION COMPLETED:
09:22 AM
NARRATIVE
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On 11/15/2024 LPAs Dwayne Mason Jr. and Nancy Guillen arrived at the facility for the purpose of conducting a Case Management visit in order to cite for deficiencies observed on 10/14/2024. LPAs met with Florence Tolentino, Administrator and explained the purpose of the visit.

LPAs observed a partial wall installed in the living room. When asked if anyone resides behind the wall in the living room, facility staff stated that two staff members sleep there. LPAs noted the wall does not reach the ceiling. LPAs determined the staff residing behind the wall in the living room are not afforded adequate privacy due to them residing in the living room of the facility behind a partial wall.

LPAs determined the facility is not in compliance with the following regulation:

PERSONAL ACCOMMODATION AND SERVICES 87307(a) The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.

Based on today's visit, one deficiency is being issued. LPAs reviewed the report with facility staff and provided a copy.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/15/2024 09:08 AM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/15/2024 at 08:25 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87307(a)

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PERSONAL ACCOMMODATION AND SERVICES 87307(a) The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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Administrator stated they will consult with the fire marshall to see if they will allow the facility to install a full wall in place of the partial wall. AD stated they will keep LPA updated on their communications with Fire Marshall and may need to request an extension in case the process takes longer than expected.
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This requirement is not met as evidenced by:

Based on observation, the licensee did not comply with the section cited above due to a staff bedrooom being placed behind a partial wall, which poses a potential personal rights risk to persons in care.
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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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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