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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600932
Report Date: 05/26/2022
Date Signed: 08/23/2022 12:34:14 PM

Document Has Been Signed on 08/23/2022 12:34 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEYTON'S PLACEFACILITY NUMBER:
198600932
ADMINISTRATOR:JOSH MAJDALIFACILITY TYPE:
735
ADDRESS:29224 SOUTH BAYEND DRTELEPHONE:
(424) 772-6289
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marvin Pinar, House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Marvin Pinar, House Manager and the purpose of today’s visit was explained.

There are currently (4) four Harbor Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, living room, kitchen, dining room, laundry area, indoor and outdoor activity area, and attached garage.

LPA and House Manager toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1, 2, 3, 4 are occupied by clients and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms are clean and operational. First aid and manual are incompliance. Smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 staff file is complete. 1 client and medications and P & I money are current. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, 2 fire extinguisher are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEYTON'S PLACE
FACILITY NUMBER: 198600932
VISIT DATE: 05/26/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the bathrooms and additional sanitation supplies in a locked cabinet located in the living room. LPA observed staff wearing masks, isolation rooms are the clients private rooms and required postings throughout the facility. The facility has an approved Mitigation plan. Visitors are logged and checked. The clients temperature's are checked and logged 2x a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Marvin Pinar, House Manger and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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