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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206616
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:08:43 PM

Document Has Been Signed on 04/28/2022 01:08 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 ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
157206616
ADMINISTRATOR:GARCES, HILDA J.FACILITY TYPE:
735
ADDRESS:6909 COPPER CREEK WAYTELEPHONE:
(661) 589-6804
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 2CENSUS: 2DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Administrator, Hilda GarcesTIME COMPLETED:
01:15 PM
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On 04/28/022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management - Other visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility by Caregiver, Khatlyn Vergara who contacted Administrator via telephone. Administrator, Hilda Garces arrived a short time later.

The purpose of this is visit is to follow up on a letter submitted to the Fresno CCL office regarding a request for facility extension.

No deficiencies issued during this inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Hilda Garces, whose signature on this form confirms receiving this documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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