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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409895
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:06:30 PM

Document Has Been Signed on 07/15/2024 03:06 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/
DIRECTOR:		ROGER HOYLEFACILITY TYPE:
735
ADDRESS:12246 SHOOTING STAR AVETELEPHONE:
(760) 955-9548
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 2DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Annmarie Antonio-StaffTIME VISIT/
INSPECTION COMPLETED:
03:16 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit and noticed that no one was present after ringing the door bell 2x. Staff, Annmarie Antonio and one client arrived shortly to the facility and granted access to LPA. LPA introduced self and stated purpose of the visit. LPA toured the facility inside and outside with Annmarie Antonio.

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 84 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting.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 which tested 114.8 degrees fahrenheit. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarm. Posters such as; the personal rights, CCL complaint poster, house rules and the emergency disaster plan were posted in a common area. 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 functioning phone in the facility. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHOOTING STAR RESIDENTIAL CARE
FACILITY NUMBER: 366409895
VISIT DATE: 07/15/2024
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Yards/Outside: LPA observed one shaded patio, a 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.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill on July 1, 2024. LPA observed that the emergency disaster plan was last reviewed/updated on 6/27/23. Technical violation issued.

No deficiencies and one technical violation was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to staff, Annmarie Antonio.

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

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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