331880564-3-23-2023-56-AS-ACON-CQ7QVB-20230323123004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880564
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:30:13 PM

Document Has Been Signed on 03/23/2023 12:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PEYTON'S PLACE BEGONIA		FACILITY NUMBER:	331880564
ADMINISTRATOR:	CROW, PEYTON RANDALL		FACILITY TYPE:	735
ADDRESS:	35230 BEGONIA LN		TELEPHONE:	(951) 257-4193
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY:	4	CENSUS: 2	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Martin Jimenez, Caregiver		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Peyton's Place -Begonia Adult Residential Facility to conduct an Annual Inspection. LPA was greeted by caregiver, Martin Jimenez. LPA introduced self and stated the purpose of the visit. Mr. Jimenez invited LPA inside and prompted to sign in, have temperature taken and complete COVID Questionnaire. Administrator Christopher Warner arrived later during the visit. LPA was informed that the current census is 2. Two residents are attending day program, while two remained in the facility. There are currently no suspicions of anyone in the facility to have COVID19. LPA's visit included a walk through of facility, review of records and staff interviews. LPA observed the facility to be tidy and orderly. 3 staff members were present during visit. All resident rooms were well kept and neat. All rooms included appropriate furniture according to regulation. Personnel Records/Training/and Staffing- LPA began review of employee records. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verifications, and current administrator certification. All records were observed to be complete according to regulations. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. All information was observed in the files to be complete. *Continued on LIC809C Form

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PEYTON'S PLACE BEGONIA	FACILITY NUMBER: 331880564
	VISIT DATE: 03/23/2023

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Food Service- LPA was present while lunch was being prepared. Staff was observed using proper food handling techniques. Sharp objects are kept in the facility's secured laundry room, in a secured cabinet. LPA observed a container with sharps. As well as cleaning solutions and laundry detergent to be kept there too. LPA observed a monthly menu posted on the kitchen counter top. The meals are adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supplies observed meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand.

Administrator informed LPA fire drills are conducted every 3 months. Last fire drill 2/6/23. Last earthquake drill 11/15/22. Fire extinguishers observed fully charged, last inspected January 16th, 2023.

No deficiencies observed during the inspection. CARE Tool utilized. An exit interview was conducted where this report was reviewed discussed and provided to Administrator.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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