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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602707
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:15:27 PM

Document Has Been Signed on 05/10/2023 01:15 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 SAN DIEGOFACILITY NUMBER:
374602707
ADMINISTRATOR:LANGWORTHY, VERONICAFACILITY TYPE:
735
ADDRESS:1973 GREY RABBIT HOLLOW LANETELEPHONE:
(760) 723-0882
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Chris WarnerTIME COMPLETED:
01:25 PM
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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez conducted an unannounced annual required visit on 5/10/2023 at 10:20 a.m. LPA was granted entry and met with Administrator, Chris Warner, who was informed of the purpose of the visit. At the time of the visit there was (5) staff and (4) clients present.

The facility is a one story home with (5) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPAs conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in locked laundry room. The smoke detector and carbon monoxide was operational, and the hot water temperature 120F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods, with emergency food supplies in the facility laundry room.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The administrator, possesses a current administrator's certificate. The administrator stated they had sent in paperwork to change administrator, and LPA requested this be sent to them for processing.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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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
RIVERSIDE, CA 92507
FACILITY NAME: PEYTON'S PLACE SAN DIEGO
FACILITY NUMBER: 374602707
VISIT DATE: 05/10/2023
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in laundry room. LPA reviewed client medications for clients and found all medication listed on MARS and all required labeling was found to be in place. LPAs did find (1) medication was expired and needed to be destroyed due to the medication being discontinued for the client. Deficiency was cited as well as plan of correction.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The plan the facility currently has on file does not meet the department requirements. This deficiency was documented along with plan of correction. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

An exit interview was conducted where a copy of this report along with deficiency page and appeal rights were reviewed and provided to the Administrator, Chris Warner.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/10/2023 01:15 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/10/2023 at 12:43 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: PEYTON'S PLACE SAN DIEGO
FACILITY NUMBER: 374602707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80023(b)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with LIC610D that was not updated to the current LIC610D that meet department standards for emergency procedures. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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The adminsitrator agreed to send the LPA the updated LIC610D by the 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 01:15 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/10/2023 at 12:56 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: PEYTON'S PLACE SAN DIEGO
FACILITY NUMBER: 374602707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80075(l)(1)
(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.
(1) Both shall sign a record, to be retained for at least one year...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with (1) medication for Client #1 (C1) that was expired and discontinued and was being stored with the routine medication. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The adminsitrator agreed to destroy the medication and send the LPA a copy of the destruction record by the 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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