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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602991
Report Date: 11/18/2021
Date Signed: 11/18/2021 04:47:07 PM

Document Has Been Signed on 11/18/2021 04:47 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RAINEBEE HOMEFACILITY NUMBER:
198602991
ADMINISTRATOR:BROMSTEAD, JOHNFACILITY TYPE:
735
ADDRESS:20514 E COVINA HILLS RDTELEPHONE:
(626) 699-2080
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 4DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lorraine Bromstead, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Bonnie Tao conducted an unannounced Case Management- Incident visit in response to Client (C1’s) Incident Report that was submitted by John Bromstead, Administrator on 11/11/21. The report was for a death that occurred on 11/11/21. LPA explained the purpose of today's visit to Lorraine Bromstead, Administrator, who assisted with this visit.

During today's visit LPA toured the facility, interviewed Administrator/Staff (S1), clients (C2- C5), and reviewed C1's file. The incident report stated C1 deceased due to complications of surgery. C1 passed away at the hospital. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

LPA obtained copies of the following documents:
· Staff roster
· Client roster
· C1’s Medication Administration Records (MAR)
· C1's Unusual Incident Report, dated 11/11/21
· C1's Identification/Emergency Contact Information (facesheet)
· C1's Individual Program Plans (IPP)
· C1's Last doctor visit dated 6/14/2021 and 10/5/2021.

(- Continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RAINEBEE HOME
FACILITY NUMBER: 198602991
VISIT DATE: 11/18/2021
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LPA requested the following documents be submitted upon receipt:
· L A County Death Report
· Coroner’s Report if applicable
· C1's Physician report
· C1's Client's Appraisal
· C1's Hospital paper
· C1's Death Report

The department will continue to gather additional information and will return to complete the investigation.

Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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