<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 03/22/2023
Date Signed: 03/22/2023 10:12:31 AM

Document Has Been Signed on 03/22/2023 10:12 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BEKIM ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881312
ADMINISTRATOR:AQUINO, LORA MAE D.FACILITY TYPE:
735
ADDRESS:4421 ANNISA AVENUETELEPHONE:
(951) 658-5272
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 5DATE:
03/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff, Adriano AguinaldoTIME COMPLETED:
10:01 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Janira Arreola and Janette Romero conducted an announced visit to the facility to conduct a prelicensing visit. The LPAs met with the staff, Adriano Aguinaldo who was informed of the purpose of the visit.

The facility is under going a change in corporation for the facility. The LPAs were informed by the staff that the administrator was not able to be at the facility at the time the LPAs arrived. The staff did not have the documentation to show the corporation change at the time of the visit, such as the Articles of Incorporation. LPAs also reviewed the LIC500 and found all staff had been fingerprinted. LPAs reviewed Aguinaldo's file and found that the TB test results were missing for the staff.

The administrator, Lora Aquino was contacted over the phone during the time of the visit and was informed of documents that would need to be presented to the LPAs on the rescheduled visit of Tuesday March 28, 2023 at 9:00 am.

An exit interview was conducted where this report was reviewed and provided to, staff Adriano Aguinaldo.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1