306004509-1-22-2025-22-AS-NGUN-DD6UT6-20250122145125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004509
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:57:03 PM

Document Has Been Signed on 01/22/2025 02:57 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BONAFIDE HOME CARE		FACILITY NUMBER:	306004509
ADMINISTRATOR/ DIRECTOR:	ERLEEN B. RINEHART		FACILITY TYPE:	740
ADDRESS:	25215 ROMERA PL.		TELEPHONE:	(949) 716-4914
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Erleen Rinehart		TIME VISIT/ INSPECTION COMPLETED:	03:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nancy Guillen and Licensing Program Manager Sheila Santos made an unannounced visit for the purpose of conducting a required annual Inspection. LPAs were greeted and granted entry by care provider Markjaydar Romuar after explaining the purpose of the visit. Administrator (AD) Erleen B. Rinehart was present at the facility and assisted with the inspection. LPA observed the Administrator Certificate expired on September 14, 2024, however LPA verified the application was submitted and received on November 10,2024 for renewal. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for two. The facility is a one-story home with five resident bedrooms, one staff bedroom, two bathrooms, and an attached garage.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

LPA observed residents watching television in the living room and having breakfast. LPA observed four residents in care and three staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the entryway. All resident bedrooms had the required furnishings however R3 had a half bed rail with no doctor’s order present at the time of visit; a Deficiency was cited on today’s date. LPA observed all resident beds had linens and blankets with additional linens stored in vacant bedrooms. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.9 and 113.1 degrees Fahrenheit. LPA toured the outside of the facility and observed outdoor passageways were not free of obstruction and hazards; a Deficiency was cited on today’s date. LPA observed the backyard had a shaded sitting area with furniture for resident use.

Continued on LIC809-C

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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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Document Has Been Signed on 01/22/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BONAFIDE HOME CARE	FACILITY NUMBER: 306004509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of four resident bedrooms, which poses an immediate health and safety rights risk to persons in care. Lysol spray was observed in R3's room accessible to the residents in care.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator immediately removed the Lysol bottle from resident's room and will provide in-service training for toxins. Documentation of training to be submitted to LPA by January 29, 2025.

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to knives being stored next to uncovered bleach cleaner, which poses an immediate health risk to persons in care.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator immediately removed knives and placed it in a locked cabinet in the kitchen effective today. Administrator to conduct an in-service training by January 29, 2025 and submit proof to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses an immediate health risk to persons in care due to unlocked staff bedroom observed to have resident's medications accessible to all the residents while waiting to be destroyed due to previously deceased resident.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator immediately locked staff bedroom and will remain locked at all times effective today. Administrator to submit proof in-service training to LPA by January 29, 2025.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above in four out of four resident's medications, which poses an immediate health risk to persons in care. Medication is transferred to a separate container and prepared 24 hrs in advance for all residents in care.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator stated that facility will no longer transfer medications to a separate container effective today. Administrator will conduct in-service training and will provide documented proof by January 29, 2025 of training to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of four resident's files which poses an immediate health, safety or personal rights risk to persons in care. R1 and R3 did not have a medical assessment (Physicians Report) upon record review.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Administrator to submit a written plan on how to correct citation and Administrator will provide by January 29, 2025 the medical assessment for R1 and R3 and submit proof to LPA.

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.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BONAFIDE HOME CARE	FACILITY NUMBER: 306004509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to carbon monoxide not functioning at time of visit, which poses a potential safety risk to persons in care.
	POC Due Date: 02/05/2025
	Plan of Correction
1 2 3 4	Administrator to have a working carbon monoxide detector by POC date.

Section Cited

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential safety risk to persons in care. The outdoor area was observed with tripping hazards, dried leaves, and gardening tools.
	POC Due Date: 02/05/2025
	Plan of Correction
1 2 3 4	Administrator to clean backyard and remove hazards by POC date. LPA to visit facility to verify POC.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2025 02:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BONAFIDE HOME CARE	FACILITY NUMBER: 306004509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four out of four staff files which poses a potential health and safety risk to persons in care. Staff records were not present at the facility for any of the staff members to review during the inspection.
	POC Due Date: 02/05/2025
	Plan of Correction
1 2 3 4	Administrator to have all staff files by POC date. LPA to conduct a visit to review records.

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a safety risk to persons in care. No proof of disaster drills was able to be provided during today's visit.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Administrator to conduct a fire drill by POC date and will continue to conduct quarterly drills.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: 01/22/2025

NARRATIVE

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LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors were tested operational, however the carbon monoxide detector was not functioning; a Deficiency was cited on today’s date. Two fire extinguishers were observed to be fully charged and located in the kitchen and living room. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage and is kept locked and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were not observed to be locked and inaccessible to residents in the R3 bedroom and unlocked staff bedroom; a Deficiency was cited on today’s date. LPA observed knives stored with bleach under the kitchen sink; a Deficiency was cited on today’s date. LPA observed the First Aid Kit had all the required components. Facility was unable to provide Disaster Drill Log at the time of visit.

Medication cabinet was observed to be locked and centrally stored by the entryway. During medication review, medication was observed to be transferred to a separate container and prepared 24 hours in advance for all residents; a Deficiency was cited on today’s visit. LPA observed three medications total for R1, R2 and R3 were still listed on the centrally stored medication log with medication still present at the facility. AD was unable to provide updated documentation of discontinued medications; a Deficiency was cited on today’s date.

LPA began review of the records. LPA reviewed four resident records. Two out of four residents did not have a Physicians Report at the facility; a Deficiency was cited on today’s date. Two out of four residents did not have an Admissions Agreement present at the facility (R1 and R3); a Deficiency was cited on today’s date.

LPA was unable to review employee records. Staff records were not present at the facility for any of the staff members to review during the inspection; a Deficiency was cited on today’s date.

Based on today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Nancy Guillen	TELEPHONE: (714) 724-3542
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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