306002474-12-13-2022-22-AS-AORZ-CNLR6R-20230131114508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002474
Report Date: 12/13/2022
Date Signed: 12/13/2022 09:58:00 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2022 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20221107110951

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: 4	DATE:	12/13/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Florence Tolentino - Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not follow COVID-19 protocols.
Staff worked at facility prior to obtaining a background check clearance.

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver findings. LPA identified themselves and was met by Florence Tolentino, Administrator and discussed the above allegations.

On 11/07/2022 the Department received allegations that staff did not follow COVID-19 protocols and staff worked at facility prior to obtaining a background check clearance. During the course of the investigation the Department interviewed staff as well as reviewed pertinent documents such as negative covid test, lic 500, staff schedules and background clearance documentation. The investigation revealed the following:

For the allegation that staff did not follow COVID-19 protocol, per interview with Administrator Florence Tolentino staff is tested prior to working in the facility. The Administrator stated that she was utlizing a lab PCR test until October 2022. CONT on LIC 9099- C dated 12/13/2022

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221107110951

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LIFESTREAM HOME CARE FOR ELDERLY	FACILITY NUMBER: 306002474
	VISIT DATE: 12/13/2022

NARRATIVE

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Administrator and 2 out of 2 staff interviewed stated they know if they are feeling sick to not come into work. Staff indicated they would quarantine while they await their COVID test results and isolate if they test positive.

Per interview with Administrator Florence no staff is allowed to work prior to obtaining a background check clearance. Review of documents revealed Staff 1 (S1) S1 was cleared on 08/12/2022 and LIC 500 indicated S1 started work on 08/18/2022.

Therefore based on the preponderance of evidence the allegations that staff did not follow COVID-19 protocol and staff worked at facility prior to obtaining a background check clearance are UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and an exit interview was conducted

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC9099 (FAS) - (06/04)

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