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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602991
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:57:08 AM

Document Has Been Signed on 02/16/2023 10:57 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
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: 5DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorraine Bromstead, Assistant Administrator TIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Assistant Administrator Lorraine Bromstead and explained the purpose of the visit. Administrator John Bromstead arrived shortly after. There are currently five (5) ambulatory level disabled clients ages of 18 through 59 serviced by San Gabriel/Pomona Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 1 staff room, 3 bathrooms, kitchen, dining room, living room, laundry room, outdoor patio, and fenced pool. The last fire/emergency drill was conducted on 8/16/2022. Administrator certificate expires 3/21/2024.
OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance areas, common areas, and bathrooms. Visitors are no longer being screened.
  • Two bedrooms are designated as a COVID-19 isolation rooms if needed.
  • A posted Emergency Disaster Plan was observed.
  • Knives were observed unlocked in the pantry area. It was immediately locked.
  • Centrally stored medications/30-day supply of medications were reviewed.
  • The facility is owner operated; therefore staff were not observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • The facility submitted a COVID-19 Mitigation, but has not submitted an Infection Control Plan (ICP). A technical advisory was issued. The plan should be reviewed and updated as necessary.
Deficiency was cited.
Exit interview was conducted with Administrator Samira Menendez. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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 02/16/2023 10:57 AM - It Cannot Be Edited


Created By: Noemi Galarza On 02/16/2023 at 10:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAINEBEE HOME
FACILITY NUMBER: 198602991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that knives were observed stored in an unlocked pantry room; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2023
Plan of Correction
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Assistant Administrator immediately locked the pantry room. CLEARED during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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