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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206616
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:04:11 AM

Document Has Been Signed on 07/27/2022 10:04 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 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:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Hilda GarcesTIME COMPLETED:
10:15 AM
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On 07/27/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (ADM), Hilda Garces. There are two residents present during today's inspection.

LPA conducted a tour of the facility with ADM. Facility staff observed to be wearing facial coverings. There were no obstructions blocking walkways or fire clearance issues during this inspection. LPA observed a visitor log/temperature log at the entry. Hand sanitizer was available for visitors. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout the facility. Resident bedrooms are single occupant. LPA observed hand sanitizer in resident rooms. Resident bathroom observed to be stocked with paper towels and liquid soap. Hand-washing signs observed in the resident bathroom and kitchen.

LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA checked medications. Facility receives new medications at the end of the month. LPA observed a 30 day supply of PPE and cleaning supplies. Staff files reviewed for good health. Resident files have updated emergency contact information.

No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/10/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020), Surety Bond

An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Hilda Garces, whose signature on this form confirms receiving this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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