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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600932
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:45:16 PM

Document Has Been Signed on 05/13/2024 03:45 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PEYTON'S PLACEFACILITY NUMBER:
198600932
ADMINISTRATOR/
DIRECTOR:		JOSH MAJDALIFACILITY TYPE:
735
ADDRESS:29224 SOUTH BAYEND DRTELEPHONE:
(424) 772-6289
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 4CENSUS: 4DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Marvin Pinar/House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 5/13/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Marvin Pinar/House Manager and the purpose of today’s visit was explained. The facility is licensed to operate for (4) (developmentally disabled or Mentally Ill) adults ages 18 through 59. Approved for (4) ambulatory only. Currently, the home has (4) clients. The clients are from: Harbor Regional Center. (0) Restricted Health Care Conditions, and (1) utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) 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 Iniguez and Administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. LPA observed the facility clean, sanitary and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathroom was found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 116.4F° & Bathroom #1 115.4F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEYTON'S PLACE
FACILITY NUMBER: 198600932
VISIT DATE: 05/13/2024
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

LPA conducted a records review of (4) client records, (4) staff records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. Last facility disaster drills were: 3/30/24. Facility licensee fees are current. Copy of Surety Bond will be email to LPA.

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


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marvin Pinar /House Manager.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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