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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881344
Report Date: 08/08/2023
Date Signed: 08/08/2023 07:31:23 PM

Document Has Been Signed on 08/08/2023 07:31 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
RIVERSIDE AC/SC, 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: 1DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Tiffany Dupree
TIME COMPLETED:
07:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA met with care provider Sherronda Davis and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, one (1) staff and one (1) client were present at the facility. LPA Shaw Ross conducted staff and client interviews.

The facility is a two story four bedroom, three bathroom home. The facility appears clean and free of odors. Client bedrooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in a locked cabinet in the kitchen. Furniture in the facility is in good repair. Outdoor space is free of hazards. LPA tested smoke alarms and smoke alarms were found operable. LPA tested hot water and the temperature level was appropriate. Emergency drills are conducted monthly. Fire extinguishers are fully charged. Client P&I was reviewed and is kept separate from facility funds.

LPA inspected the staff and client records. Staff files had the required First Aid Certifications and training documents however during the inspection LPA observed the following deficiencies:

LPA reviewed facility roster on Guardian and compared this to Employee files provided by the Licensee. Licensee informed LPA that three staff members started employment at this facility as of yesterday, 08/07/2023.







L

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: POSITIVE IMPACT HOME
FACILITY NUMBER: 331881344
VISIT DATE: 08/08/2023
NARRATIVE
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LPA reviewed files for all staff and found three (3) staff members (S1, S2, and S3) did not have background clearance documents on file. Licensee stated all three (3) staff members started yesterday, 08/07/2023. LPA was informed S1 was transferred to this facility from Licensee's other facility, Concept For Life, however Licensee did not initiate transfer of clearance request as of yet. LPA reviewed files for S2 which show S2 has been employed with this facility since 12/30/2022 however no Background Clearance documentation was included in employee file. LPA reviewed file records for S3 which show employee has been employed with this facility since 1/2/2023 however no Background Clearance documentation was included in employee file. This is a zero tolerance regulation and a Type A citation will be assessed with civil penalties in the amount of $100 per staff, for two days totaling $600.

Facility medication/PRN logs were reviewed and resident’s medications were inspected for daily dispensing according to physician’s orders. LPA observed the following deficiency:



-Medications were not being dispensed from their original containers - LPA observed medication pre-prepared and stored in a pill tray.

Based on observations made by LPA, the facility was cited and deficiencies noted on LIC809D. An exit interview was conducted with Licensee Tiffany Dupree and a copy of this report, LIC809D, LIC811, LIC429BG and appeal rights was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2023 07:31 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 08/08/2023 at 06:33 PM
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: POSITIVE IMPACT HOME
FACILITY NUMBER: 331881344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)(f)
"Criminal Record Clearance
(e) All individuals subject to a criminal recored review pursuant to Health and Safety Code Section 1522 shall prior to working, resideing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)..."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with S1, S2 and S3 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. A civial penalty will be assessed in the amount of $600.
POC Due Date: 08/22/2023
Plan of Correction
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Licensee will submit updated LIC9182 for S1, and LIC508 for S2, S3 to the department by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/08/2023 07:31 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 08/08/2023 at 07:00 PM
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: POSITIVE IMPACT HOME
FACILITY NUMBER: 331881344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(6)
The following requirements shall apply to medications which are centrally stored. No medications shall be transferred between containers.

This requirement is not met as evidenced by: Medications were observed to be stored in pre-prepared in a medication pill tray. Medication is to be dispensed directly from its original containers to residents.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1] out of [total 1] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2023
Plan of Correction
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Licensee will conduct an in-service training regarding residents' medication and storing them in original containers. Licensee agrees to submit staff roster and training material to the Department by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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