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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602707
Report Date: 03/19/2025
Date Signed: 03/19/2025 12:29:16 PM

Document Has Been Signed on 03/19/2025 12:29 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:
03/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:58 AM
MET WITH:Acting Administrator, Marchelino RoosTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 3/19/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to conduct a case management visit to deliver an Immediate Exclusion order for Staff, Christian Umana. LPA was greeted and granted entry by Caregiver, Josue "David" Medrano who was informed of the purpose of the visit. During the visit, Acting Administrator (AA) Marchelino Roos arrived to the facility to meet with LPA and was also informed of the purpose of the visit.

During today's visit, LPA toured the facility’s interior and exterior with Caregiver Medrano and did not observe Umana present in the facility. LPA phoned Licensee, Peyton Crow who estimated Umana was last present in the facility on approximately July/August of 2024. Licensee reported Umana never resided in the facility. LPA provided AA Roos the Immediate Exclusion order dated 3/18/2025 regarding Umana. No citations were issued during today’s visit. An exit interview was conducted and this report was reviewed over the phone with Licensee Crow and in person with AA Roos. A copy of this report was provided to AA Roos.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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