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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880573
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:26:16 AM

Document Has Been Signed on 03/25/2022 11:26 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
CCLD Regional Office,
, CA
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:
03/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Chris Warner, Activing AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs), Stephanie Torres and Chinwe Nwogene, conducted an unannounced visit to the facility to amend complaint #18-AS-20200115115243. The LPAs met with Acting Administrator, Chris Warner, and informed him of the purpose of the visit.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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