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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003801
Report Date:
01/26/2023
Date Signed:
01/26/2023 03:29:17 PM
Document Has Been Signed on
01/26/2023 03:29 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:
01/26/2023
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Wesley Laceste- Caregiver, Florence Tolentino- Administrator
TIME COMPLETED:
03:45 PM
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On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez made an unannounced visit to conduct a collateral complaint investigation visit. This visit is in conjunction with complaint control # 22-AS-20221107110951 at Lifestream Home Care for Elderly. LPAs were greeted and granted entry by Caregiver Wesley Laceste and explained the reason for the visit. Administrator Florence Tolentino arrived at 3:16PM.
During the visit LPAs interviewed staff.
An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-4084
LICENSING EVALUATOR NAME:
Andrea Mendivil
TELEPHONE:
714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2023
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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