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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880573
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:53:04 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200115115243
FACILITY NAME:PEYTON'S PLACE HARVARDFACILITY NUMBER:
331880573
ADMINISTRATOR:CROW, PEYTON RANDALLFACILITY TYPE:
735
ADDRESS:36069 HARVARD CTTELEPHONE:
(951) 208-7309
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:4CENSUS: 4DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Josh Majdali, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff hit client
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Stephanie Torres and David Cuevas conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA's were greeted by staff and later met with Administrator, Josh Majdali. Majdali was informed of the purpose of the visit.

Pertaining to the allegation, "Staff hit client", it was alleged Staff One (S1) punched Client One (C1) in the ribs. The investigation was initiate on January 21, 2020; interview was conducted, records were reviewed and copies of pertinent documentation was obtained. C1 was interviewed and stated S1 had hit them in the ribs, though did not indicate when this incident had occurred. S1 was interviewed and denied the allegation. Additional staff/client interviews were conducted; no reports of concerns pertaining to the care S1 provides were received. Photos and medical records of C1 were received showing bruising/hematomas at the hip and lower stomach areas. No other information was received. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A findings that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200115115243

FACILITY NAME:PEYTON'S PLACE HARVARDFACILITY NUMBER:
331880573
ADMINISTRATOR:CROW, PEYTON RANDALLFACILITY TYPE:
735
ADDRESS:36069 HARVARD CTTELEPHONE:
(951) 208-7309
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:4CENSUS: 4DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Josh Majdali, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff refused to take client back into care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Stephanie Torres and David Cuevas conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPAs were greeted by staff, and later met with Administrator, Josh Majdali. Majdali was informed of the purpose of the visit.

Regarding the allegation, "Staff refused to take client back into care", it was alleged facility Administrator, Josh Majdali, relinquished care of Client One (C1) from the facility by refusing to pick up the client following an incident during transportation. The investigation was initiated on January 21, 2021; interview was conducted, records were reviewed, and copies of pertinent documentation were obtained. Majdali was interviewed and reported he informed the police officer who had arrived on scene he and the Licensee requested the client be evaluated due to physically assaulting a transportation driver as he was being taken back to the facility. A police report and third party interview corroborated the Administrator's statement; however, it was also reported C1 did not qualify for an emergency hold to have a psychological evaluation. Therefore, based on record and interview, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200115115243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PEYTON'S PLACE HARVARD
FACILITY NUMBER: 331880573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/20/2021
Section Cited
CCR
80072(a)(1)
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PERSONAL RIGHTS: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Administrator stated a statement indicating regulation was reviewed and understood.
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Based on a police report it was revealed facility staff failed to pick up C1 who did not qualify for a mental health evaluation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200115115243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEYTON'S PLACE HARVARD
FACILITY NUMBER: 331880573
VISIT DATE: 10/13/2021
NARRATIVE
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the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued.

An exit interview was conducted with Majdali in which this report was reviewed and a copy provided, in addition to LIC 811 and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200115115243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEYTON'S PLACE HARVARD
FACILITY NUMBER: 331880573
VISIT DATE: 10/13/2021
NARRATIVE
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alleged violation occurred.

An exit interview was conducted with Majdali in which this report was reviewed and a copy provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5