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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411428
Report Date: 05/23/2023
Date Signed: 05/23/2023 02:10:21 PM

Document Has Been Signed on 05/23/2023 02:10 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: 1DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Desiree McClain, House ManagerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA Coleman) and Mary Rico, (LPA Rico) arrived at the Big Dipper Adult Residential Facility unannounced to conduct the Annual Inspection. LPA's introduced themselves to staff who granted LPA's entry. LPA's signed in and were provided with a space to work.

During today's visit, LPA's conducted a general overall inspection of the facility, interviews with staff and residents, and a file review. The facility is vendorized by the Inland Regional Center, (IRC).

The facility has 3 residents bedrooms, 1 staff room, 2 bathrooms, a kitchen, dining area, a den, living room, attached garage, and backyard. LPA observed 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 comfortable temperature. LPA inspected resident bedrooms; they are each equipped with required furniture such as: mattresses, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found operational. LPA tested the temperature from the kitchen faucet, which read at 109 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms - which were tested during the visit. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept secure and inaccessible in the garage. Staff and resident files are kept in the staff room which is kept secure. Medications are kept in a secure file cabinet in the dining room. Each resident has their own labeled bin for their prescribed medications. The facility was also equipped with emergency and first aid kits readily available for clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BIG DIPPER RESIDENTIAL CARE
FACILITY NUMBER: 366411428
VISIT DATE: 05/23/2023
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Food Service: Non-perishable and perishable food supply offers a variety of options sufficient for the number of residents in care. Dishes, cups, and utensils were observed and sufficient. Emergency food and water were also observed in the garage.
Care & Supervision: Facility includes care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance and fingerprint clearance through the department.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Fire /Earthquake drills are conducted on a monthly basis. Last fire drill conducted on 5/1/23. No unusual occurrences noted.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. An exit interview was conducted where this report was reviewed, discussed and provided to facility representative.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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