<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411428
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:12:39 PM

Document Has Been Signed on 02/20/2025 12:12 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/
DIRECTOR:		ROGER HOYLEFACILITY TYPE:
735
ADDRESS:12196 BIG DIPPER CIRCLETELEPHONE:
(760) 843-5527
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 1DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:48 AM
MET WITH:Desiree McClain-DSPTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Annmarie Antonio and DSP, Desiree McClain and introduced self and stated purpose of the visit. LPA was informed that the facility has 1 client who is at program.

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, medication 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 73 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 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, house rules, 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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 5
Document Has Been Signed on 02/20/2025 12:12 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/20/2025 at 11:28 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not having an Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will submit a copy of the Infection Control Plan to the LPA via email by POC due date and maintain an updated copy in the facility.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not providing window screens in the kitchen, reception area and client's master bedroom in good condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will replace the window screens in the kitchen, reception area and master bedroom and send a picture to the 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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/20/2025 12:12 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/20/2025 at 11:28 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not reporting two client's incidents that occurred last year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.
Type B
Section Cited
CCR
85064(e)
Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not following the posted schedule accordingly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will update the schedule and have the administrator follow accordingly. Licensee stated that he will provide a copy 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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/20/2025 12:12 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/20/2025 at 11:28 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaing an updated IPP for the client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will obtain an updated IPP and maintain it in the client's file. Licensee stated that he will provide a copy to the LPA via email by POC due date.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not reviewing/updating the Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
1
2
3
4
Licensee stated that he will review/update the Emergency Disaster Plan and submit a statement of understanding on the regulation cited to LPA via email by POC.
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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 02/20/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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. LPA observed broken window screens in the kitchen, front reception room, and client's master bedroom. Deficiency issued.

Record Review: LPA reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the administrator's schedule was not being followed accordingly. Deficiency issued. LPA reviewed the client's file for admission agreement, updated physician report, and needs and services plan. LPA observed that the client's IPP was not updated since 2019. Deficiency issued. Medication was audited and appeared to be dispensed appropriately. 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 that the facility did not report two incidents that occurred last year for two different clients. Deficiency issued. LPA observed that the facility did not have an Infection Control Plan. Deficiency issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated since 6/27/23. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and copies were provided to DSP, Desiree McClain.

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

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5