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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409895
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:18:20 PM

Document Has Been Signed on 06/23/2023 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 0DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Desiree McClain-ManagerTIME COMPLETED:
03:23 PM
NARRATIVE
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On 06/23/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. Per last phone conversation with Administrator Roger Hoyle, he stated to be notified upon arrival in order to send Staff to grant access to the facility since it's been unoccupied for many months. LPA called Administrator and stated that Staff would arrive within 15 minutes. Manager, Desiree McClain arrived to the facility and granted access to LPA. LPA toured the facility inside and outside with Manager. LPA observed that there are currently no clients admitted to the facility.

The facility has 3 bedrooms (2 for clients and 1 for Staff), 2 bathrooms (1 for clients and 1 for Staff), a kitchen, dining area, living room, laundry room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 73 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA observed missing chairs in clients bedrooms. Manager stated to be unaware of missing chairs. Technical violation issued. There is an adequate supply of linens and blankets stored in a closet in the main hallway of the residence. LPA inspected clients bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet, which tested within regulation. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarm. Posters such as; the personal rights, and the emergency disaster plan were posted in a common area. LPA observed that the Emergency Disaster plan was last reviewed on May 01, 2016. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. LPA observed that there is a phone in the facility, yet the service is disconnected. Technical violation issued. LPA also observed that there is no internet access. Technical violation issued. Manager stated that phone and internet services will be restored before accepting clients. There are no pools, bodies of water, firearms or ammunition.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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Document Has Been Signed on 06/23/2023 03:18 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/23/2023 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SHOOTING STAR RESIDENTIAL CARE
FACILITY NUMBER: 366409895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Manager did not comply with the section cited above in reviewing annually the Emergency Disaster Plan which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Manager stated that she will annually review the Emergency Disaster plan and update if needed. Manager stated that she will submit the updated Emergency Disaster Plan to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHOOTING STAR RESIDENTIAL CARE
FACILITY NUMBER: 366409895
VISIT DATE: 06/23/2023
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Yards/Outside: One shaded patio furniture for outdoor seating observed. Side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Food Service: There is no non-perishable and perishable food supply due to no clients in care. Manager will purchase food before accepting clients. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the Administrator's file and 1 Staff file for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Deficiency and technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to Manager, Desiree McClain.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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