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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881344
Report Date: 08/02/2022
Date Signed: 08/02/2022 10:45:33 AM

Document Has Been Signed on 08/02/2022 10:45 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
08/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tiffany Dupree - ApplicantTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit. Analyst met with Applicant Tiffany Dupree and toured the facility. Fire Clearance was granted for one (4) ambulatory residents on 6/9/22 by the City of Menifee Fire Department. The facility is going to apply to be vendorized through Inland Regional Center for developmentally disabled adults ages 18 - 59 once licensed. Home is set-up with living room, family room, kitchen, dining room, four (4) resident bedrooms, 2 restrooms, den, backyard, laundry room, and a garage.

LPA Colvin observed required accommodations in residents' bedroom and bathrooms including inspection of beds, mattresses, and closet space. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when she tested them. Common areas such as dining and living rooms were observed to be clean and in good condition.

ADMINISTRATION/MEDICATION: Medication is to be stored in a locked cabinet in the kitchen and a file cabinet for record storage. Staff records include documentation on training for medication administration for all staff.

PHYSICAL PLANT: Outside premises were inspected for potential hazards. Cleaning solutions and other hazardous items are stored and locked in the cabinet under the kitchen sink. Outside gate was observed to be unlocked for clients' and staff's use in case of emergency as an exit. Exit route from backyard was observed to be free of obstruction. LPA Colvin tested the facility's hot water and observed it to be measuring at 92.4 degrees. LPA Colvin instructed applicant to raise the temperature of the hot water heater and measure again at a later date to ensure it does not exceed 120 degrees but is at least 105 degrees.
ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with outdoor furniture and a shaded area for the residents. Facility additionally has magazines, tv, books, and games for the residents to use.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: POSITIVE IMPACT HOME
FACILITY NUMBER: 331881344
VISIT DATE: 08/02/2022
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FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Trash can has tight-fitting lid. Dishes, utensils and glasses are present and in sufficient number for residents and staff. Dishwasher will be used to clean and sanitize dishes. Knives will be kept locked and out of clients' reach for safety purposes. All need appliances were present and shown to be in working condition and clean. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7 day requirements. Facility additionally has emergency supply of food and water as well as first-aid kit.

EMERGENCY EXIT PLAN: Facility has an emergency exit plan in place an posted in plain view at the facility, along with operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Facility additionally has adequate Personal Protective Equipment (PPE) and a screening station at the front entrance of the facility to screen all entering staff and visitors. Applicant has completed and submitted an Infection Control plan for the facility as well.

Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant will be notified of the license approval.

An exit interview was conducted with Applicant Tiffany Dupree and a copy of the report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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