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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 05/11/2023
Date Signed: 05/11/2023 10:38:20 AM

Document Has Been Signed on 05/11/2023 10:38 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:
05/11/2023
TYPE OF VISIT:Case Management - Health ChecksANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lead Staff, Adriano AguinaldoTIME COMPLETED:
10:45 AM
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On 5/11/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit at the facility for the purpose of conducting a health and safety check. LPA Arreola met with staff, Adriano Aguinaldo, and explained the purpose of the visit.

At the time of the visit there was (4) staff and (2) clients present. Client 1 (C1) was sitting in the living room, Client #2 (C2) was in their bedroom. (3) clients were at their day programs. LPA conducted a tour of the facility's interior and exterior. LPA observed the staff room, clients rooms, bathrooms, outdoor space, laundry room, and kitchen and dining areas. LPA reviewed the staff schedule during the time of the visit. All staff possessed a cleared background check.

No health and safety issued were observed during the time of the visit.

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: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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