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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880573
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:42:17 AM

Document Has Been Signed on 03/13/2023 11:42 AM - 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 HARVARDFACILITY NUMBER:
331880573
ADMINISTRATOR:CROW, PEYTON RANDALLFACILITY TYPE:
735
ADDRESS:36069 HARVARD CTTELEPHONE:
(951) 208-7309
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martin Jiminez, Staff MemberTIME COMPLETED:
11:45 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Peyton's Place Harvard Adult Residential Facility unannounced to conduct an Annual Inspection. LPA was greeted at the door, by staff member Martin Jiminez, (S1). LPA introduced self and stated the purpose of the visit. LPA was granted entry and agreed to sign in and have temperature taken. S1 contacted facility Administrator Christopher Warner who later arrived during the visit. LPA was informed that the current census is 3. Two resident were at their prospective day programs. 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.

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 verification, and current administrator certification. All records were observed to be complete.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Three (3) 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.

Food Service- LPA was present after breakfast. Staff was observed cleaning the kitchen. Sharp objects are kept in the facility's secured laundry room, in a cabinet. LPA observed a container with sharps. LPA also observed cleaning chemicals 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 supply 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 1/7/23. Last earthquake drill 11/15/22. Fire extinguishers observed fully charged, last inspected Jan. 2023.

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

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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