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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004509
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:55:29 PM

COMPREHENSIVE INSPECTION
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:BONAFIDE HOME CAREFACILITY NUMBER:
306004509
ADMINISTRATOR:ERLEEN B. RINEHARTFACILITY TYPE:
740
ADDRESS:25215 ROMERA PL.TELEPHONE:
(949) 716-4914
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Erleen Rinehart, Administrator
Pancho Roxas, Caregiver
Rosita Roxas, Caregiver		TIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility and was greeted and granted entry by Pancho Roxas, caregiver after being screened for COVID-19 symtpoms. Staff called administrator Erleen Rinehart who arrived shortly after during the tour of the physical plant. LPA explained the nature of the visit and conducted it with the present caregiver.

There are currently 5 residents in care including two residents on hospice. Some of the residents are observed relaxing in the common area, while others are in their own rooms. All appear relaxed and well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station at the main entry of the facility.
Facility is taking residents' temperatures on a daily basis and documenting the results. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted. LPA observed a sufficient supply of food and water. Facility has an adequate supply of PPE stored. LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris. Facility bedrooms are both shared and single occupancy. All bedrooms were observed to have all required components. Bathrooms are equipped with grab bars and anti-skid mats. Medications are stored in locked drawers and in adequate quantity for 15 to 30 days depending on the residents' approved choice of pharmacy. The facility has completed the LIC808 Mitigation Plan, LPA Norman Powell reviewed and approved the plan on 07/15/2021. LPA Powell emailed the signed and approved plan to the Administrator for their records.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
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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