157206616-9-18-2023-24-AS-LSAR-CVSL36-20230918082326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206616
Report Date: 09/15/2023
Date Signed: 09/18/2023 08:23:32 AM

Document Has Been Signed on 09/18/2023 08:23 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 FACILITY		FACILITY NUMBER:	157206616
ADMINISTRATOR:	CASTILLO, MYRA CELESTE		FACILITY TYPE:	735
ADDRESS:	6909 COPPER CREEK WAY		TELEPHONE:	(661) 589-6804
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93308
CAPACITY: 2		CENSUS: 2	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Hilda Garces, Licensee		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/15/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Staff and Licensee, stated the purpose of the visit and was allowed entry into the facility. Staff S1 provided a tour of the facility inside and out. LPA observed 2 residents in care at the time of visit. Facility is a 3 bedroom 2 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 76 degrees F. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 105 degrees F. Trash can with lid and hand washing postings were observed. Medications were observed to be locked in a cabinet in the hallway. Cleaning supplies were observed to be locked in the garage. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Carbon monoxide and smoke detectors were observed to be operational. Fire Extinguisher was observed with a service date of 08/22/23. First aid kit was observed and contained all required items. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
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 ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 157206616
	VISIT DATE: 09/15/2023

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(Continued from 809)

Residents’ files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP). A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility.

The following documents are requested and submitted to Fresno CCL by: 10/01/23:
LIC 308, LIC309 (If Applicable) LIC 400, LIC 402, LIC 500, Copy of current Administrator certificate and Emergency and Disaster Plan (LIC610D)

An exit interview was conducted with Licensee. A copy of this report was discussed and provided at the time of visit. No deficiencies cited on today's visit.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
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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