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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:23:48 PM

Document Has Been Signed on 03/29/2023 03:23 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:
03/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff, Arnie EsperaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the facility in order to conduct a prelicensing visit. The LPA met with staff, Arnie Espera and spoke with applicant Lora Aquino over the phone. The staff were informed of the purpose of the visit. At the time of the visit there were (5) staff and (5) clients present.

The applicant is seeking a change within the corporation from Neldy's R.C. INC to Bekim Adult Residential Care Home INC. The population served is adults ages 18 to 59. LPA reviewed the prelicensing materials submitted by the applicant such as the facility sketch, emergency disaster plan, and infection control plan. LPA also reviewed the current administrator's certificate posted at the facility for Lora Aquino which was current with an expiration date of 5/31/2023. All these documents were found to be in compliance with department requirements. LAP reviewed the articles of incorporation sent by the applicant.

The facility is a one story home with (4) bedrooms and (2) bathrooms. (3) bedrooms are shared for clients, and (1) room is being used as a staff room. The fire clearance dated 10/26/2022 completed by Hemet fire department indicated the facility is licensed for 6 residents. The facility is approved for (4) ambulatory, (2) of which can be non-ambulatory. The LPA was informed and observed that there are no fire arms, or bodies of water such as pool present at the facility.

LPA observed the resident and staff bedrooms and bathrooms. Bathrooms had grab bars, and hand hygiene supplies as well as client individual hygiene supplies. The resident bedrooms were observed to have required furniture. LPA observed emergency water and emergency food, radios, and first aid kit in facility garage. LPA also observed emergency backpacks in the facility kitchen under the resident medications. LPA observed the facility laundry equipment was function, and observed locked cleaning supplies. The facility has enough supplies to conduct regular cleaning of the facility. LPA observed the medication cabinet where first aid kit and resident medications were stored. The facility kitchen had enough pots, pans, and cooking utensils and functional appliances to prepare food for clients. The food supply observed to be a 2-day perishable and 7-day non-perishable food requirements.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331881312
VISIT DATE: 03/29/2023
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The facility poses a required carbon monoxide detector and smoke alarms. Required facility posting such as resident person rights, ombudsmen and complaint information, emergency phone numbers, as well as emergency exits where found posted in the facility.

The facility yard was observed to be free of hazards and had a shaded area with furniture for facility clients.

Component III orientation was conducted during the visit with the applicant over the phone Lora Aquino. An exit interview was conducted where this report was reviewed and provided to the staff, Arnie Espera.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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