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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880573
Report Date: 09/08/2021
Date Signed: 09/08/2021 04:32:53 PM

Document Has Been Signed on 09/08/2021 04:32 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
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: 4DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Gina ChavarriaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced case management visit to discuss an incident report received at the Community Care Licensing Regional Office on 8/30/2021. LPA met with direct care staff Gina Chavarria and spoke with administrator Josh Majdali via telephone. Licensee/administrator Peyton Crow arrived during the visit.

During the conversations with client 1,and Mr. Mejdali regarding events surrounding the incident, Mr. Mejdali stated this incident occurred around January 11, 2021 and that he did submit an incident report to CCL on or around 1/12/2021.
Both C1 and Mr. Mejdali stated that when staff asked C1 to turn down their phone due to the content and late hour and suggested C1 put the phone away and go to bed, C1 became agitated and attempted to push and punch the staff when staff had asked C1 to turn down the volume on their phone. Mr Mejdaliu stated that the staff member did work here with their spouse but did not have a minor living at the facility. He stated the employee is no longer an employee as they resigned due to another job offer. Mr Mejdali stated C1 admitted to him and to the doctor that C1 had become agitated during this incident.

An exit interview was conducted where this report was discussed and provided to Mr. Crow.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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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