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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602991
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:52:45 PM

Document Has Been Signed on 02/04/2022 04:52 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:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lorraine Bromstead,
and John Bronstead, Licensee		TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve six (6) ambulatory clients from age 18-59. Client census is four (4). The facility is vendorized through San Gabriel/Pomona Regional Center. The annual fee is current. LPA met with Lorraine Bromstead, and John Bronstead, both Licensees, who assisted with visit. LPA discussed with licensee of the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility inside and outside. Facility is a single-story home located in a residential neighborhood consisting of four (4) bedrooms, three and a half (3 & 1/2) bathrooms, kitchen, living room, laundry room and dining room with sufficient dining capacity. LPA observed medications which were locked and centrally stored in a closet. Staff and client records are locked in a closet and inaccessible to clients. The kitchen had all necessary equipment and supplies. Hazardous items were locked and inaccessible to clients. A shaded area with chairs was provided at the outdoor activities area. The secured pool at the backyard which was not in use with a locked gate was inaccessible to the clients.

(- continued in LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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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: 02/04/2022
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Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser and closet space available. Bathrooms are operational. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Carbon monoxide detectors and smoke detectors are operable. Hot water temperature is measured at 114.8 degrees Fahrenheit which is in compliance. Hazardous items are locked and inaccessible to clients. Fire extinguisher was fully charged and last service was on 8/27/21. Last disaster drill was conducted on 11/2/21. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications were properly logged and current. Administrator certificate is current with expiration date on 3/21/22.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to Licensee, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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