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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880573
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:43:25 PM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220916103613
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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Christopher Wagner- AdministratorTIME COMPLETED:
01:53 PM
ALLEGATION(S):
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Resident was not accorded safe, healthful, and comfortable accommodations.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA Gardner met with Administrator Christopher Wagner and explained the reason for the visit. At the time of the visit, there were two (2) clients, and four (4) staff present.

During today’s visit, LPA toured the facility, reviewed facility documents, interviewed staff, and interviewed clients.

For allegation: Resident was not accorded safe, healthful, and comfortable accommodations:

During today’s tour, LPA found that the garage has been converted into recreational room for the clients. The garage has a couch, a TV, video games, arcade games, and chairs. LPA discovered that two (2) clients were residing in the garage upon arrival to the facility. One (1) client (C1) was sitting on the couch watching TV and the other client (C2) was sitting on a chair reading a book.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 3
Control Number 56-AS-20220916103613
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
, CA 92507
FACILITY NAME: PEYTON'S PLACE HARVARD
FACILITY NUMBER: 331880573
VISIT DATE: 09/22/2022
NARRATIVE
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During interviews with clients and staff, it was found that the clients spend portions of the morning, afternoon, and evening in the garage.

During document review, LPA discovered that the facility sketch lists the garage as a garage, not a recreational room.

Based on the information found and provided, the allegation listed above is deemed SUBSTANTIATED.
A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During today’s visit, one (1) type B deficiency was cited per Title 22, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Christopher Wagner, along with a copy of the LIC-9099D form, and a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220916103613
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
, CA 92507

FACILITY NAME: PEYTON'S PLACE HARVARD
FACILITY NUMBER: 331880573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
80087(a)
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80087. Buildings and Grounds. (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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The licensee has agreed to read regulation 80087 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to remove the recreational items and furniture out of the garage. The licensee has agreed to send LPA pictures of the garage once it is cleared out, as well of pictures of the area in the facility
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observation, interview, and record review. The licensee did not comply with the section cited above by converting the garage into a recreational room. The garage is not deemed an as a recreational area per the facility sketch which poses a potential health, safety, or personal rights risk to persons in care.
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where the recreational items and furniture have been relocated to. The POC is due by 10/14/2022.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3