306004509-1-30-2024-22-AS-CDPO-CZYQ92-20240130105737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004509
Report Date: 01/30/2024
Date Signed: 01/30/2024 10:58:12 AM

Document Has Been Signed on 01/30/2024 10:58 AM - 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BONAFIDE HOME CARE		FACILITY NUMBER:	306004509
ADMINISTRATOR:	ERLEEN B. RINEHART		FACILITY TYPE:	740
ADDRESS:	25215 ROMERA PL.		TELEPHONE:	(949) 716-4914
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Facility Administrator - Erleen Rinehart		TIME COMPLETED:	11:22 AM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA was greeted and granted entry by staff on duty. LPA met with facility administrator (AD) Erleen Rinehart and explained the purpose of today's visit.

For today’s visit, LPA observed a total of 6 residents in care of which 0 are on hospice and 0 are bedridden and 4 staff members on duty.

LPA observed the Administrator's Certificate for facility Erleen Rinehart which expires on 09/14/2024. The PUB475 "See Something, Say Something" poster was also observed to be posted in the entrance of the facility.

LPA toured the interior and exterior portions of the facility with AD Rinehart. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 2 may be on hospice and 1 may be bedridden. There are a total of 7 bedrooms, of which 6 are designated for residents, and 1 is designated for staff.

LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms, of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 112.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen and in the living room.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BONAFIDE HOME CARE	FACILITY NUMBER: 306004509
	VISIT DATE: 01/30/2024

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LPA observed the emergency disaster and evacuation plan which posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA observed patio furniture under shading, the grounds were free of any hazards, and that there are 2 gates in the backyard, of which both were self-closing and self-latching.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Rinehart.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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