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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:42:20 PM

Document Has Been Signed on 04/13/2023 03:42 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, 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:
04/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:John Calimag, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit due to deficiencies observed during LPA's complaint visit conducted on today's date. LPA met with John Calimag, Caregiver and explained the purpose of the visit.

LPA conducted a record review of five (5) staff files, for the staff that were present at the time of LPA's visit. LPA observed for two (2) of the five (5) staff files reviewed to have expired First Aid/CPR cards. Staff # 2 (S2) and First aid/CPR expired on March 26, 2023 and staff #3 (S3) First aid/CPR expired on October 3, 2022. Deficiency cited.

These deficiencies are documented on the attached LIC 809-D and are cited in accordance with the California Code of Regulations, Title 22.


An exit interview was conducted, and a copy of this report, 809D, and appeal rights were provided to John Calimag, Caregiver .
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 2
Document Has Been Signed on 04/13/2023 03:42 PM - It Cannot Be Edited


Created By: Javina George On 04/13/2023 at 02:15 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BEKIM ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Personnel Requirements-General. Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross...
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The Licensee agrees to have S2, S3 enrolled in CPR/first aid training, by 5pm on the due date indicated. in addition once completed the certificates/proof of completion will be submitted to the department.
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Based on observation and record reivew this requirement is not met as evidenced by Staff 2' and 3's first aid certification has expired. These staff need updated first aid certification. This poses an immediate health, safety and personal rights risk to persons in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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