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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203178
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:08:02 PM

Document Has Been Signed on 09/02/2021 04:08 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ST. THERESE III ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
157203178
ADMINISTRATOR:GARCES, HILDAFACILITY TYPE:
735
ADDRESS:4204 MIRA LOMA COURTTELEPHONE:
(661) 589-6804
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Petronila Alegre, House ManagerTIME COMPLETED:
12:45 PM
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On 9/2/21 at 11:05 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA met with House Manager Petronila "Nila" Alegre. Licensee/Administrator Hilda Garces was unavailable for inspection, but was available by telephone. Hilda gave permission via telephone for Nila to sign today's report.

LPA toured inside and outside of facility. Facility was observed clean and without any obstructions. Hand sanitizer was readily available to residents and visitors. All residents have private rooms. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Administrator certification is valid.

No deficiencies cited during inspection. No fire safety issues.

Licensee is to submit the following updated forms to CCL within 2 weeks:
LIC500, LIC610D, LIC308, LIC400, and current surety bond

Exit interview conducted. A copy of this report was emailed to Licensee Hilda Garces at HILDAG3842@YAHOO.COM.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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