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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411428
Report Date: 04/25/2023
Date Signed: 04/25/2023 12:30:38 PM

Document Has Been Signed on 04/25/2023 12:30 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:BIG DIPPER RESIDENTIAL CAREFACILITY NUMBER:
366411428
ADMINISTRATOR:ROGER HOYLEFACILITY TYPE:
735
ADDRESS:12196 BIG DIPPER CIRCLETELEPHONE:
(760) 843-5527
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 0DATE:
04/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Annmarie Antonio, House ManagerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Big Dipper Residential Care Facility to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA was greeted by Annmarie Antonia, House Manager and granted entry. Due to technical difficulties, LPA was unable to complete the annual inspection. LPA will rescheduled the annual inspection for a different date.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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