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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602707
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:05:25 PM

Document Has Been Signed on 05/03/2024 12:05 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PEYTON'S PLACE SAN DIEGOFACILITY NUMBER:
374602707
ADMINISTRATOR/
DIRECTOR:		LANGWORTHY, VERONICAFACILITY TYPE:
735
ADDRESS:1973 GREY RABBIT HOLLOW LANETELEPHONE:
(760) 723-0882
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Christopher Warner, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 5/3/24 Licensing Program Analyst (LPA) Javina George made an unannounced 1 year required visit to the facility. LPA was greeted and granted entry by Caregiver Diego Mora where LPA explained the purpose of the visit. One of the Administrator's Christopher Warner arrived shortly after. At the time of the visit there was (3) staff and (4) residents present. LPA observed for there to be two (2) staff to not have obtained proper fingerprint clearance and one (1) staff to not be associated to the facility. A citation will be issued, Staff #2 (S2) and Staff #3 (S3) staff were sent home and informed that they could not return to work until proper fingerprint clearance has been obtained. Per an interview with Christopher the facility is having a difficult time gaining access to the Guardian system, LPA reviewed an email that was sent dated 1/11/24 confirming what was reported. Below is what was observed during today's inspection:

The facility single story home with (5) bedrooms and (3) bathrooms with attached garage. In the garage half is used as a recreation room and the other is used for storage. The facility serves clients adults between the ages of 18-59. The facility has an approved mitigation plan on file that was submitted 6/10/21.

The facility was observed to be clean, clutter and odor free. The passage ways were observed to be free from obstruction. LPA observed the furniture throughout the facility to be in good repair. Laundry equipment was observed to be operable, as both the washer and dryer were in use during LPAs visit. The sharp and hazardous items such as medications were observed to be locked and inaccessible to residents and are stored in the locked cabinet inside the locked laundry room.



LPA conducted a review of resident medication, and the medications were observed to be given according to the physician instructions. The smoke and carbon monoxide detectors were tested and were observed to operable. The facility has one fully charged fire extinguisher that is hanging on the wall inside the kitchen just before the laundry room. There are no known guns or ammunition, on the premises. The are no pools or bodies of water on the premises. The emergency disaster drills are being conducted on a quarterly basis and the last drill conducted was on 2/4/24.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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Document Has Been Signed on 05/03/2024 12:05 PM - It Cannot Be Edited


Created By: Javina George On 05/03/2024 at 11:04 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
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:

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 in 2 out of 2 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2024
Plan of Correction
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2
3
4
The licensee agrees to have S2 and S3 obtain fingerprint clearance and associate thme to the facility prior to working and providing care and supervision. POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2024 12:05 PM - It Cannot Be Edited


Created By: Javina George On 05/03/2024 at 11:04 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations and interview, the licensee did not comply with the section cited above in 2 out of 2 times which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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The licensee agrees conduct a review/audit of staff files and ensure that each employee has a file at the facility available for review. POC is due to the department by 5pm the due indicated.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PEYTON'S PLACE SAN DIEGO
FACILITY NUMBER: 374602707
VISIT DATE: 05/03/2024
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LPA observed for the facility food supply to meet the requirements as they were observed to have the required 2-day supply of perishable and 7-day supply of non-perishable food. LPA observed 3 boxes of expired macaroni and cheese, that was discarded during LPAs visit. The facility was observed to have a alarm on the refrigerator, that has the sensor deactivated as it is covered by tape. Because the mechanism does not prevent the residents from accessing the food, no citation was issued. LPA did discuss with Chris should the needs change then a request for waiver or exception would be needed. The residents Personal and Incidental (P&I) was reviewed and all money indicated on the P&I log was present and accounted for.

The facility was observed to have the required postings such as PUB475 CCL compliant poster, facility sketch, Emergency disaster plan. The administrator on record should be Natalie Chea and poses a current administrator's certificate that expires 8/13/25. A change of administrator request will be submitted by 5pm today 5/3/24.

Records review: LPA attempted to review 4 staff files, however only 2 files were at the facility to review at the time of LPAs visit. The resident files were observed to have the required documentation such as admissions agreement, appraisals, medical assessment, IPP.

Based on today's inspection a citation will be issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted and a copy of this report 809D, LIC421BG, appeal rights and LIC9098 proof of Corrections form was reviewed and provided to Christopher Warner, Administrator.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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