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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003801
Report Date: 10/14/2024
Date Signed: 10/14/2024 02:45:36 PM

Document Has Been Signed on 10/14/2024 02:45 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LIFESTREAM HOME CARE IIFACILITY NUMBER:
306003801
ADMINISTRATOR/
DIRECTOR:
TOLENTINO, FLORENCEFACILITY TYPE:
740
ADDRESS:8361 SUNNYBROOK CIRCLETELEPHONE:
(714) 228-0022
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Florence Tolentino - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Administrator Florence Tolentino. LPA explained the purpose of the inspection.

The facility is one-story home with four resident bedrooms, three resident bathrooms, kitchen, dining room, living room, staff room, den, attached 2-car garage and backyard with pool. Pool is enclosed on all four sides. Two sides are enclosed by a brick wall separating the yard from neighboring yards. The other two sides are enclosed by an iron fence. The iron fence has two locked gates. One resident bedroom has patio that leads to the pool area, however the gate leading from the patio to the pool area is permanently locked. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 10/14/2024 according to the attached service tag.


Smoke/Carbon Monoxide detector were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the dining area. Exit gate is unlocked and self-latching. LPA observed exit gates to be unobstructed. LPA reviewed three resident files and three staff files. LPAs also reviewed medication for three residents. LPA interviewed one staff and one resident.

Based on today's inspection, no citations are being issued. An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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