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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 07/25/2023
Date Signed: 07/25/2023 02:19:46 PM

Document Has Been Signed on 07/25/2023 02:19 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:
07/25/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Caregiver John CalimagTIME COMPLETED:
02:45 PM
NARRATIVE
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On 7/25/2023 at 1:05 p.m. Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to conduct a health and safety check at the facility. LPA met with Caregiver John Calimag who was informed of the purpose of the visit.

At the time of the visit there was four (4) staff and two (2) clients present. LPA was informed three (3) clients were at day program. Staff present had a criminal background clearance and were associated to the facility. LPA conducted a tour of the facility's interior and exterior. LPA observed both clients in the living room. LPA observed client restroom did not have toilet paper and towels readily available for client use. LPA observed facility stores toilet paper and towels in top restroom cabinet that is tied with a ribbon lanyard. Caregiver Calimag informed LPA that Client #1 (C1) attempts to flush hand towels and rolls of toilet paper down the toilet. Caregiver Calimag stated that facility staff removed toilet paper rolls from toilet paper holder and made towels inaccessible to avoid the toilet from clogging. Caregiver Calimag stated towels and toilet paper are given to clients on an as needed basis.

LPA issued civil penalties for repeated violations from 6/14/2023's visit.

Caregiver Calimag stated C1 has a meeting with Inland Regional Center (IRC) Service Coordinator Margie Swafford today at 3:00 p.m., where facility staff plan on addressing C1's behavior and seeking guidance from IRC Service Coordinator Swafford.

An exit interview was conducted, where a copy of this report was reviewed and provided to Caregiver Calimag along with an LIC809-D, LIC421FC and Appeals Rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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 08/29/2023 11:01 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/24/2023 03:12 PM


Created By: Janette Romero On 07/25/2023 at 01:25 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
RIVERSIDE AC/SC, 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: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
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 maintain the restroom cabinet storing client towels unlocked/untied movingforward and provide staff training. Proof of correction to be submitted to CCLD by close of business on 8/4/2023.
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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. Facility stores client towels in top restroom cabinet that is tied with ribbon lanyard.
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Type B
08/04/2023
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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Facility agreed to maintain the restroom cabinet storing client toilet paper unlocked/untied movingforward and provide staff training. Proof of correction to be submitted to CCLD by close of business on 8/4/2023.
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During tour of the restroom, LPA observed toilet paper is not readily available for client use. Facility stores client toilet paper in top restroom cabinet that is tied with ribbon lanyard.
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*This report is an amended version of the original report.
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: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023


LIC809 (FAS) - (06/04)
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