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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:08:00 AM

Document Has Been Signed on 08/29/2023 11:08 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
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:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Caregiver, John CalimagTIME COMPLETED:
11:15 AM
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On 8/29/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a Case Management visit for the purpose of obtaining signatures and amending the LIC809-D issued on 7/25/2023. LPA was greeted and granted entry by Caregiver John Calimag who was informed of the purpose of the visit.

During today’s visit, LPA conducted a tour of the facility and did not observe any issues or concerns.

The LIC809-D page delivered today is an amended version of the original report due to database issues experienced on 7/25/2023, which did not capture signatures made to the original report. LPA also amended the section cited to reflect the correct citation.

A copy of this report was reviewed and provided to Caregiver Calimag.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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