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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:15:33 PM

Document Has Been Signed on 06/14/2023 03:15 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
RIVERSIDE AC/SC, 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:
06/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver Arnie EsperaTIME COMPLETED:
03:30 PM
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On Wednesday, 6/14/2023, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit to the facility at 12:30 p.m. LPA was granted entry by Caregiver Arnie Espera who was informed of the purpose of the visit. At the time of the visit, there were 2 clients present and 3 at day program. The clients served are adults between the ages of 18-59. There was a total of four staff who were all cleared and associated to the facility.

The facility is made up of a one-story home with three (3) client bedrooms, one client (1) bathroom, a family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior, and reviewed facility documents. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage, and lighting. Facility has operable smoke alarm/carbon monoxide detectors, in accordance with Title 22 regulations.

Bathrooms: Client bathroom has a working toilet, wash basin, and was equipped with a grab bar in the shower. The facility has clean blankets and linen, available in different colors for each client. Facility did not have hygiene kits available for clients. Facility did not have non-slip mat in client shower, towels, or toilet paper in client bathroom.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sample menu is posted on the refrigerator door and activity schedule is posted on kitchen wall. The stove is operational. Refrigerator and freezer were in working condition. Facility has a 2-day supply of perishable and 7-day supply of non-perishable food. Fire extinguisher is charged and mounted on kitchen wall.

Continued on LIC809-C
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BEKIM ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881312
VISIT DATE: 06/14/2023
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Centrally Stored Medications: LPA observed a first aid kit with required components, and locked area for medication storage.

Living/Family room: The family room had a working television. Let-Us-No poster, emergency phone numbers, and facility sketch were posted in the kitchen area. Client records are stored in a locked file cabinet in the family room.



Yard/Outside Area: Covered patio seating is available for six (6) clients. A brick wall secured the backyard. LPA observed a black steel screen door in disrepair placed against the outdoor brick wall, near the exit pathway. LPA observed an empty hot tub in the patio, which was secured with a wood cover and lock. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Garage(s): Laundry washer and dryer are in the garage. During tour of the garage, LPA observed unsecured laundry detergent in the unlocked garage.

Deficiencies: Licensee stated they will provide a non-slip mat in client shower and make toilet paper and towels available in client restroom. Licensee stated they will remove door in disrepair and secure laundry detergents and cleaning solutions to make them inaccessible for clients. During the visit, caregiver staff created hygiene kits for each client.

An exit interview was conducted, and a copy of this report was discussed and provided to Caregiver Espera along with LIC 421FC, LIC809-Ds and Appeal Rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/14/2023 03:15 PM - It Cannot Be Edited


Created By: Janette Romero On 06/14/2023 at 02:23 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
80087(g)(1)

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(g) Disinfectants, cleaning solutions...and other items that could pose a danger...to clients shall be stored...inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement was not met as evidenced by:
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Facility agreed to provide staff training to ensure disfectants, cleaning solutions and laundry detergents are secured and inaccessible to clients in care.

Proof of correction will be provided to CCLD by COB on 6/15/2023.
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Based on observation and interview, LPA found laundry detergenty in unlocked garage. This poses an immediate health and safety risk to clients 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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/14/2023 03:15 PM - It Cannot Be Edited


Created By: Janette Romero On 06/14/2023 at 02:31 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
85088(c)(4)

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The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. Clean linen in good repair, including lightweight, warm blankets.... and bath towels, hand towels and washcloths. This requirement was not met as evidenced by:
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Facility agreed to provide clean towels available for clients in care. Proof of correction to be submitted to CCLD by close of business on 6/22/2023.
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Based on observation and interview, facility did not have bath towels readily available in client showers, posing a potential health and safety risk to clients in care.
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Type B
06/23/2023
Section Cited
CCR85088(c)(5)

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The licensee shall ensure provision to each client of the following... supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. This requirement was not met as evidenced by:
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During the visit, caregiver staff created hygiene kits for each client and provided toilet paper in client bathroom.
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Based on observation and interview, facility did not have hygiene items/kits and toilet paper available for clients, which poses a potential health and safety risk to clients 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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/14/2023 03:15 PM - It Cannot Be Edited


Created By: Janette Romero On 06/14/2023 at 02:43 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
80087(b)(1)

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(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs. This requirement was not met as evidenced by:
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Facility agreed to provide non-slip mat in client shower and provide proof to CCLD by 6/22/2023.
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Based on observation and interview, client shower was not equipped with a non-slip mat.
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Type B
06/22/2023
Section Cited
CCR80087(c)

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(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement was not met as evidenced by:
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Facility stated they will remove steel screen door in disrepair and maintain outdoor passage ways free of obstruction in the future. Facility will provide proof of correction to CCLD by 6/22/2023.
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Based on observation and interview, facility did not maintain outdoor passage way free of obstruction due to black steel screen door in disrepair placed against the outdoor brick wall, near the exit pathway. This poses a potential health and safety risk to clients 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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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