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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306002474
Report Date:
01/27/2023
Date Signed:
01/27/2023 03:19:41 PM
Document Has Been Signed on
01/27/2023 03:19 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
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
LIFESTREAM HOME CARE FOR ELDERLY
FACILITY NUMBER:
306002474
ADMINISTRATOR:
FLORENCE TOLENTINO
FACILITY TYPE:
740
ADDRESS:
5165 SOMERSET STREET
TELEPHONE:
(714) 228-9788
CITY:
BUENA PARK
STATE:
CA
ZIP CODE:
90621
CAPACITY:
6
CENSUS:
5
DATE:
01/27/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Mark Aguila- Caregiver
TIME COMPLETED:
03:30 PM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit for the purpose of obtaining additional information for Complaint Control # 22-AS-20221107110951.
LPA interviewed residents and responsible parties.
An exit interview was conducted and a copy of this report was left at facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
01/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/27/2023
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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