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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881344
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:48:47 AM

Document Has Been Signed on 07/08/2022 11:48 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:POSITIVE IMPACT HOMEFACILITY NUMBER:
331881344
ADMINISTRATOR:DUPREE, TIFFANYFACILITY TYPE:
735
ADDRESS:33275 DOLOMITE STTELEPHONE:
(323) 921-8391
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 0DATE:
07/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tiffany Dupree, Licensee/AdministratorTIME COMPLETED:
11:48 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Tiffany Dupree, Licensee/Administrator
Interview Method: Telephone interview

On July 8, 2022 at 11:00 AM, Licensee/Administrator participated in COMP II. Identification of the Licensee/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Licensee/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Licensee/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Licensee/Administrator. Email report and inform to return sign copy by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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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