331881312-8-29-2023-18-AS-JROO-CV6PQV-20230829113146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881312
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:31:49 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/29/2023 11:31 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 HOME		FACILITY NUMBER:	331881312
ADMINISTRATOR:	AQUINO, LORA MAE D.		FACILITY TYPE:	735
ADDRESS:	4421 ANNISA AVENUE		TELEPHONE:	(951) 658-5272
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 6		CENSUS: 5	DATE:	08/29/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Caregiver John Calimag		TIME COMPLETED:	12:00 PM

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On 8/29/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a Required 1-year visit. LPA was greeted and granted entry by Caregiver John Calimag who was informed of the purpose of visit. During the visit, there was two (2) clients and two (2) staff present and LPA was informed that three (3) clients were at day program.

The facility is approved to care for four (4) ambulatory clients and (2) non-ambulatory clients and serves adults ages 18-59. LPA toured the facility's interior and exterior. During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Knives/sharp instruments were secured in a locked kitchen drawer. A fire extinguisher is charged and mounted in the kitchen.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed clients in their room and in common areas.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

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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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: 08/29/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for Client #1 and Client #2 as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. Bathrooms had toilet paper and bath towels readily available for clients. The hot water temperature measured at 105-degrees Fahrenheit. The facility has plenty of clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked garage. Emergency food supplies, water, additional linen, PPE, and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff present have a current CPR/First Aid certification.

Yard/Outside Area: Covered patio seating is available for clients. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. 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.

During today's visit, LPA did not observe any deficiencies. An exit interview was conducted, and 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

LIC809 (FAS) - (06/04)

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