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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881344
Report Date: 08/06/2024
Date Signed: 08/06/2024 12:51:15 PM


Document Has Been Signed on 08/06/2024 12:51 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 ASC, 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: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Tiffany DupreeTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Tiffany Dupree, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present. The clients were out in the community.

The facility is a two story home with (4) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The cleaners were observed to be locked during the visit. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detector was operational, and the hot water temperature 118F. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The food supply met department requirements with provisions for doctor ordered diets. LPA reviewed the staff scheduled. LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (2) client files were reviewed, and possessed all required paperwork.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: POSITIVE IMPACT HOME
FACILITY NUMBER: 331881344
VISIT DATE: 08/06/2024
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All client medication was locked. LPA reviewed client medications for all clients and found all medication listed on MARS was accounted for. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 6/1/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies such as first aide kit.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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