306003801-10-13-2022-22-AS-ETAA-CK6UAJ-20221013152448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003801
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:25:09 PM

Document Has Been Signed on 10/13/2022 03:25 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 II		FACILITY NUMBER:	306003801
ADMINISTRATOR:	TOLENTINO, FLORENCE		FACILITY TYPE:	740
ADDRESS:	8361 SUNNYBROOK CIRCLE		TELEPHONE:	(714) 228-0022
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Florence Tolentino		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator Florence Tolentino arrived during the inspection. The facility is a single level structure and licensed for five non-ambulatory residents with a hospice waiver for four. One may be bedridden. This facility is a Residential Care Facility for the Elderly. At about 1:41 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms, 2 of which were shared rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured between 107.6 degrees Fahrenheit. LPA noticed cleaning supplies in bathroom. Staff immediately removed cleaning supplies from bathroom. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard contained a swimming pool with a locked gate surrounding the pool. Facility offers a 2-car garage which is used for storage, an extra refrigerator and an operational washer/dryer.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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: LIFESTREAM HOME CARE II	FACILITY NUMBER: 306003801
	VISIT DATE: 10/13/2022

NARRATIVE

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, One deficiency was noted in areas observed. One advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Florence Tolentino and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/13/2022 03:25 PM - It Cannot Be Edited

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: LIFESTREAM HOME CARE II	FACILITY NUMBER: 306003801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 medications were unlocked in resident's room, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2022
	Plan of Correction
1 2 3 4	Administrator was able to make the correction during the inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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