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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411428
Report Date: 02/07/2024
Date Signed: 02/07/2024 11:31:15 AM

Document Has Been Signed on 02/07/2024 11:31 AM - 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: 3DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Desiree McClain-DSPTIME COMPLETED:
11:36 AM
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On 2/7/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Monica Edwards and introduced self and stated purpose of the visit. LPA was informed that there are 3 clients at home.

The facility has 3 bedrooms, 2 bathrooms, kitchen, dining area, living room, family room, office, backyard, and attached garage. LPA completed a walk through of facility, review of records and P&I audit.

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 of 74 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 115.9 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. LPA observed the telephone jack in the common area not functioning while the second telephone is inside the locked office. Techncal violation issued. Posters such as; the personal rights, disaster plans and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearms or ammunition in the facility. 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. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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: BIG DIPPER RESIDENTIAL CARE
FACILITY NUMBER: 366411428
VISIT DATE: 02/07/2024
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right 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.

Record Review: LPA reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed one staff file without documentation of either a criminal record clearance or exemption. Technical violation issued. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. LPA observed two missing admission agreements for two clients. Deficiency issue. LPA observed a missing physician's report for one client. Deficiency issued. P & I funds were counted at random and matched with the ledger. LPA reviewed facility's file for fire drills, surety bond and insurance policy. LPA observed the infection control plan not reviewed and updated. Technical violation issued.

Technical violations and deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to DSP, Desiree McClain who later arrived.

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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2024 11:31 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/07/2024 at 11:00 AM
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: BIG DIPPER RESIDENTIAL CARE
FACILITY NUMBER: 366411428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the administrator did not comply with the section cited above in obtaining two admission agreements for two clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator stated that he will obtain the two missing admission agreements for the two clients and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the administrator did not comply with the section cited above in obtaining a physician's report for one client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator stated that he will obtain the missing physician's report for the client and submit proof to LPA via email by POC due date.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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