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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203178
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:41:15 AM

Document Has Been Signed on 09/15/2022 11:41 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, 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:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Hilda Garces, Licensee/AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 9/15/22 at 8:50 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Licensee/Administrator Hilda Garces arrived about 30 minutes later.

LPA conducted facility tour with staff. No fire issues or obstructions observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Staff files checked for health assessments. Administrator certificate is valid.

The following deficiencies were observed:
1. Hot water in hallway bathroom measured at 122.9 degrees F.
2. LPA observed one can of comet cleaner accessible in cabinet under kitchen sink; storage unit in garage where all chemicals are stored was observed with padlock, but padlock was not secured making the chemicals accessible; kitchen drawer where knives are kept was left unlocked and accessible; and two knives were left on top the cutting board on top the kitchen counter.
3. Window screen frame for bedroom #1 was observed bent in the middle of the right side.
4. S1 did not have a health screening completed and has been working in the facility since 6/24/22.

The following forms are to be submitted to CCL within two weeks: LIC500, LIC610D, LIC400, LIC402

Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee Hilda Garces, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 3
Document Has Been Signed on 09/15/2022 11:41 AM - It Cannot Be Edited


Created By: Malia Thao On 09/15/2022 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ST. THERESE III ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 157203178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed one can of comet cleaner accessible in cabinet under kitchen sink; storage unit in garage where all chemicals are stored was observed with padlock, but padlock was not secured making the chemicals accessible; kitchen drawer where knives are kept was left unlocked and accessible; and two knives were left ontop the cutting board ontop the kitchen counter, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee immediately placed knives in kitchen drawer, and locked the kitchen drawer and storage unit. POC cleared during inspection.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water in hallway bathroom measured at 122.9 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will submit proof of hot water in hallway bathroom measuring within regulation to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/15/2022 11:41 AM - It Cannot Be Edited


Created By: Malia Thao On 09/15/2022 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ST. THERESE III ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 157203178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Window screen frame for bedroom #1 was observed bent in the middle of the right side, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will submit proof of window screen replaced to CCL by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 did not have a health screening completed and has been working in the facility since 6/24/22, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will submit proof of a completed health assessment for S1 to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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