331880564-1-6-2025-56-AS-MBRN-DCNVVW-20250106154700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880564
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:47:08 PM

Document Has Been Signed on 01/06/2025 03:47 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	PEYTON'S PLACE BEGONIA		FACILITY NUMBER:	331880564
ADMINISTRATOR/ DIRECTOR:	CROW, PEYTON RANDALL		FACILITY TYPE:	735
ADDRESS:	35230 BEGONIA LN		TELEPHONE:	(951) 257-4193
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Administrator Christopher Warner		TIME VISIT/ INSPECTION COMPLETED:	03:51 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	On 01/06/2025 at 12:50 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by Administrator Christopher Warner and gained access at the home. LPA Brown explained the purpose of the visit to Administrator Christopher Warner. The facility has five (5) bedrooms, two and a half (2 1/2) bathrooms, kitchen, dining room, living room, attached garage, laundry room and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, Personal and Incidentals (P&I) audit and medications audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed no client during the visit. The four (4) clients’ were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 102.9 degrees Fahrenheit. Deficiency will be issued. During the visit, Administrator Warner adjusted the the hot water temperature in clients' shared bathroom to 111.3 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detector, charged fire extinguisher, and first aid kit with first aid book. Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. * Continuation in LIC809C *

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PEYTON'S PLACE BEGONIA	FACILITY NUMBER: 331880564
	VISIT DATE: 01/06/2025

NARRATIVE

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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed three (3) client files for admission agreements, medical assessments/physician reports, Centrally Stored Medication List, Individual Program Plan (IPP) and Pre-placement Appraisal (LIC603). LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR and Emergency Intervention/CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed Staff #3 (S3) criminal background clearance was not transferred to the facility prior to employment on 07/15/2024. Deficiency will be issued and civil penalty of $500.00 today, 01/06/2025 and will continue to be assessed of $100.00 per day until corrected. During the visit today, 01/06/2024, Administrator Warner submitted completed form LIC9182 with S3 government issued ID to LPA Brown. Also, LPA Brown observed Staff #1 (S1) Health Screening Report does not have the required physician signature. Deficiency will be issued. Moreover, LPA Brown observed Staff #1 (S1) Health Screening Report with the Tuberculosis (TB) Test result without the required physician signature and LPA Brown noted that there's no other TB test result document maintained in S1 file. Deficiency will be issued.

LPA Brown audited two (2) clients’ medications and no issues were observed. LPA Brown audited two (2) client's P&I and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC421BG and Appeal Rights were discussed, and copies were provided to Administrator Christopher Warner.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/06/2025 03:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PEYTON'S PLACE BEGONIA	FACILITY NUMBER: 331880564
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) Health Screening Report has the required physician signature and not just stamp from the medical office which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Licensee stated to provide an appointment date for S1 physician to sign the Health Screening Report or submit a copy of Health Screening Report with physician signature and submit proof to LPA Brown by the Plan of Correction (POC) due date.

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) health screening report with the tuberculosis (TB) Test result or other TB test result document maintained in S1 file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Licensee stated to provide an appointment date for S1 and S2 physician to sign the Health Screening Report with the TB Test Result or an appointment date for a TB Test fro S1 by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/06/2025 03:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PEYTON'S PLACE BEGONIA	FACILITY NUMBER: 331880564
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the hot water temperature in clients shared batrhroom's not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as LPA Brown observed the hot water temperature at 102.9 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	During the visit, Administrator Warner adjusted the hot water temperature in clients' shared bathroom to 111.3 degrees Fahrenheit. Plan of Correction (POC) cleared.

Section Cited

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) criminal background clearance was not transferred to the facility prior to employment on on 07/15/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	During the visit today, 01/06/2024, Administrator Warner submitted completed form LIC9182 with government issued ID to LPA Brown. POC cleared.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

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