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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880573
Report Date: 01/06/2025
Date Signed: 01/06/2025 12:30:05 PM

Document Has Been Signed on 01/06/2025 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PEYTON'S PLACE HARVARDFACILITY NUMBER:
331880573
ADMINISTRATOR/
DIRECTOR:		CROW, PEYTON RANDALLFACILITY TYPE:
735
ADDRESS:36069 HARVARD CTTELEPHONE:
(951) 208-7309
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 4DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Christopher WarnerTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On 01/06/2025 at 09:15 AM, 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 a staff and gained access at the home. LPA Brown explained the purpose of the visit to the staff. Administrator Christopher Warner was contacted and arrived during the visit. LPA Brown explained the purpose of the visit to Administrator Warner.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medications audit and Personal & Incidental (P&I) audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed two (2) clients during the visit. Two (2) clients’ were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 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 107.9 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 ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
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
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 HARVARD
FACILITY NUMBER: 331880573
VISIT DATE: 01/06/2025
NARRATIVE
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During the tour of the facility, LPA Brown observed the den was converted to a client bedroom and per records review and interview, the Licensee did not submit a letter to CCLD regarding the alteration made and no building permit was obtained from the city prior to construction. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left 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 four (4) client files for admission agreements, medical assessments/physician reports, Centrally Stored Medication List and Individual Program Plan (IPP). 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 07/14/2024. Deficiency will be issued and civil penalty of $500.00 and will continue to be assessed of $100.00 per day per citation until corrected. Also, LPA Brown observed no physician signature in Health Screening Report for Staff #1 (S1) and Staff #2 (S2). Deficiency will be issued. Moreover, LPA Brown observed no physician signature on Health Screening Report with the Tuberculosis (TB) Test result and no TB Test result document attached for Staff #1 (S1) and Staff #2 (S2). 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 issue 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.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
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 5
Document Has Been Signed on 01/06/2025 12:30 PM - It Cannot Be Edited


Created By: Melody Brown On 01/06/2025 at 11:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) and Staff #2 (S2) health screening report have the required physician signature, not just a 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
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Licensee stated to provide an appointment date for S1 and S2 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.
Type A
Section Cited
CCR
80066(a)(11)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) and Staff #2 (S2) health screening report with the tuberculosis (TB) Test result have the required physician signature, not just a stamp from the medical office or a TB Test Result Document for S1 and S2
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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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 and S2 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
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 5
Document Has Been Signed on 01/06/2025 12:30 PM - It Cannot Be Edited


Created By: Melody Brown On 01/06/2025 at 11:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
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
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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 record clearance was transferred to the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2025
Plan of Correction
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Licensee stated to transfer S3 criminal background clearance to the facility and submit proof to LPA Brown by the Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
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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Document Has Been Signed on 01/06/2025 12:30 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Melody Brown On 01/06/2025 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not informing CCLD of the proposed change at the facility prior to construction or alteration of the den that was observed converted to a client bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee stated to submit a letter to Community Care Licensing Division (CCLD) regarding the alterations made at the facility of converting the den to client bedroom with the building permit attached from the city building permit department by the plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
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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