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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409895
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:18:57 PM

Document Has Been Signed on 06/07/2022 03:18 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SHOOTING STAR RESIDENTIAL CAREFACILITY NUMBER:
366409895
ADMINISTRATOR:ROGER HOYLEFACILITY TYPE:
735
ADDRESS:12246 SHOOTING STAR AVETELEPHONE:
(760) 955-9548
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Attempted Annual VisitTIME COMPLETED:
12:20 PM
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LPA Lama attempted to make an unnnounced visit to the facility for the purposes of an annual inspection. LPA knocked on the door and rang the doorbell several times however no one answered.

Soon afterwards an individual who claimed to be groundskeeper for the home and a neighbor, Witness #1 (W1) approached LPA asked what LPA was doing at the home. The LPA identified himself to W1. W1 asked for ID and LPA showed W1 his Work ID. W1 then stated that everyone in the home had just gone on a shopping trip. LPA thanked W1 for his time.

LPA attempted to call the number provided, but received an automated message that the call could not be completed. LPA called teh alternate number provided and the call went to Voicemail. LPA left a detailed message and a call back number. LPA called a few more times. LPA waited approximately 10-15 minutes in hopes that the Administrator would show up. No one showed up while LPA waited outside the facility. LPA left the facility.

LPA will make another visit when time permits.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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