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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600932
Report Date: 05/17/2023
Date Signed: 05/22/2023 07:51:42 AM

Document Has Been Signed on 05/22/2023 07:51 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
EL SEGUNDO, 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:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Caregiver Marvin PinarTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual visit. LPA was met by house manager Marvin Pinar and the purpose of today’s visit was explained. The facility is licensed to serve four (4) ambulatory, developmentally-disabled adults ages 18 through 59, residents are South Central Regional Center residents.

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 that houses an additional freezer and serves as a pantry.

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 and 4 are occupied by clients and contain the mandated furniture. Bedroom 5 is a staff bedroom. There are two restrooms, 1 is a private restroom located in resident bedroom # 4, bathrooms are clean and operational. First aid and manual are incompliance. Smoke detectors and carbon monoxide detector were in compliance and operational. Medications are stored, locked and inaccessible to clients. 4 staff files were reviewed and are complete. 4 client files and Medication Administration Records were reviewed and did not observe any discrepancies at the time of visit. 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. Landline was observed. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

During today’s visit no discrepancies were observed.

Exit interview conducted with house manager Marvin Pinar and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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