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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203178
Report Date: 09/15/2023
Date Signed: 09/18/2023 10:39:36 AM

Document Has Been Signed on 09/18/2023 10:39 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:CASTILLO, MYRA CELESTEFACILITY TYPE:
735
ADDRESS:4204 MIRA LOMA COURTTELEPHONE:
(661) 589-6804
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Myra Celeste CastilloTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Administrator, Myra Celeste Castillo, and discussed the purpose of the visit. All clients were out of the facility in appointments.

LPA Williams began the tour in the front door entry way. Required facility postings were observed in the facility.

The living room was sanitary and had space to accommodate all clients. Smoke detector and carbon monoxide detector were present and operational. Facility thermostat reflected approximately 77 degrees Fahrenheit (F).

The dining room was sanitary and had a table with enough seats to accommodate all clients. The kitchen was next to the dining room and was also sanitary. There was two days of perishable food and seven days of nonperishable food. Refrigerator temp reflected approximately 36 degrees F and sink water 117 degrees F.

LPA observed four clients bedrooms to be sanitary and free of obstruction. Each room had a bed, with required linens, chair, lamp, and dresser.

There are two bathrooms in the facility for client use. Both bathrooms were sanitary and free of obstruction. The showers had non-slip mats and grab boors for client use, and the bathroom lights were operational. Sink water reflected approximately 108 degrees F.

*Continued on LIC 809C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ST. THERESE III ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 157203178
VISIT DATE: 09/15/2023
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The backyard is free of obstruction and has a covered area for clients to remove themselves from direct sunlight. There is no pool on the premises.

LPA observed medications and cleaning chemicals to be locked and inaccessible to clients.

LPA reviewed two employee files and four clients files. All files had required documents that the LPA requested.

There was no deficiency observed during this visit.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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