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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602707
Report Date: 05/30/2025
Date Signed: 05/30/2025 01:57:54 PM

Document Has Been Signed on 05/30/2025 01:57 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:		CHRISTOPHER WARNERFACILITY TYPE:
735
ADDRESS:1973 GREY RABBIT HOLLOW LANETELEPHONE:
(760) 723-0882
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Administrator, Christopher WarnerTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 5/30/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Jesus "David" Salvador who was informed of the purpose of the visit. Shortly after, Administrator Christopher Warner arrived to the facility to meet with LPA. The facility has a fire clearance to serve four (4) clients of which one (1) may be non-ambulatory. During today's visit, LPA also observed Staff 1 (S1), Staff 2 (S2), and four (4) clients present.

Upon arrival, LPA conducted a record review and discovered Caregiver Salvador is not associated to the facility. Upon further review, it was determined Caregiver Salvador does not currently possess a criminal record clearance or exemption to be able to work in the facility. Salvador's training records list his hire date as 3/10/2025. Upon learning the information, Warner immediately directed Caregiver Salvador to leave the facility until further notice and LPA observed Caregiver Salvador leave the premises. Warner reported they received a clearance letter for Caregiver Salvador from the Department's Caregiver Provider Management Branch. Warner reported administrative staff searched for the clearance letter in the facility's main office, but was unable to locate it during LPA's visit. Warner reported Caregiver Salvador will not return to work in the facility or visit the facility until they receive confirmation from the Department that Caregiver Salvador has been granted a criminal record clearance or exemption.

LPA toured the facility with Warner and observed the facility is made up of a one-story home with four (4) client bedrooms, two (2) restrooms, a kitchen, dining area, living room, laundry room, and attached garage. Indoor and outdoor pathways are free of obstructions. No bodies of water were observed on the premises. Client bedrooms were clean, had the required bedding, furniture, and lighting.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/30/2025
NARRATIVE
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NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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: 05/30/2025
NARRATIVE
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Medications are secured in a locked laundry room cabinet. LPA toured the garage and observed half of the garage is used as a recreation area. LPA observed three (3) of four (4) clients initially watching television in the recreation area and then moving to the living room to continue watching television. The other half of the garage is used for storage. Administrator Warner tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed two (2) charged fire extinguishers mounted in the facility last serviced on January 2025. The facility's certificate of liability insurance expires on 10/21/2025. S1 and S2 have a criminal record clearance and are associated with the facility.

During tour of the kitchen, LPA observed the facility did not meet Departmental requirements for a two-day supply of perishable foods. When asked to see the non-perishable foods, S1 reported the key to the pantry storing the non-perishables had been misplaced since this morning. Warner reported the pantry remains locked due to Client 1 (C1) and Client 2's (C2's) diagnosis. However, there is no record the facility obtained a waiver/exception from Community Care Licensing in order to lock the pantry storing the only non-perishable foods/snacks available for the clients. When asked, Warner reported the facility does not have an additional supply of non-perishable food accessible to Client 3 (C3) and Client 4 (C4). Warner added C3 and C4 walk to the pantry accompanied by staff who then uses a push pin to open the pantry and give them access to non-perishable foods/snacks. LPA reviewed C3 and C4's current physician reports noting they do not require a special diet. During the visit, S2 located the push pin and was able to open the pantry door. LPA observed the facility had a seven-day supply of non-perishable foods and two (2) 30-day non-perishable emergency food containers. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources for all four (4) clients and observed Warner count their physical monies. Based on C3's Record of Client's/Resident's Safeguarded Cash Resources' latest balance dated 5/15/2025 and physical monies counted during today's visit, C3 was missing $41. During the visit, Warner reported S1 provided him the $41 that they were holding onto as they updated C3's records. Warner reported staff is instructed to update the clients' Record of Client's/Resident's Safeguarded Cash Resources as soon as the clients arrive home after spending their monies. The facility will be cited for the deficiencies noted.

An exit interview was conducted and a copy of this report, LIC 809-D, LIC 421BG, Confidential Names list (LIC 811), and Appeal Rights were reviewed and provided to Administrator Warner.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 01:57 PM - It Cannot Be Edited


Created By: Janette Romero On 05/30/2025 at 12:42 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: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
HSC
1522(b)(1)(D)
1522 Fingerprints and criminal records; exemptions; criminal record clearances
(b) (1) In addition to the applicant, this section is applicable to criminal record clearances and exemptions for the following persons:
(D) Any staff person, volunteer, or employee who has contact with the clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not comply with the section cited above by allowing Caregiver, Jesus "David" Salvador to work in the facility without a current criminal record clearance or exemption, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Once Warner was informed LPA determined Caregiver Salvador does not currently possess a criminal record clearance or exemption to work in the facility, Warner immediately directed him to leave the facility until further notice. LPA observed Caregiver Salvador leave the facility premises. POC cleared. Additionally, Warner reported Caregiver Salvador will not return to the facility until they obtain a criminal record clearance or exemption.
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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 01:57 PM - It Cannot Be Edited


Created By: Janette Romero On 05/30/2025 at 12:57 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: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80024(b)(2)
80024 Waivers and Exceptions
(b) The licensing agency shall have the authority to approve the use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the contact of experimental or demonstration projects under the following circumstances:
(2) The applicant or licensee shall submit to the licensing agency a written request for a waiver or exception, together with substantiating evidence supporting the request.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as there is no record the facility submitted a written request to obtain a waiver or exception to lock the only non-perishable foods available which stored in the pantry. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2025
Plan of Correction
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Administrator reported the pantry will no longer be locked unless the facility is granted a waiver/exception to do so. Administrator added they will remove the locking mechanism on the pantry door by close of business on Monday, 6/2/2025. Administrator reported they will email LPA a written waiver/exception requesting to lock the pantry door and provide supporting documentation for the request by close of business on 6/30/2025.
Request Denied
Type B
Section Cited
CCR
80026(h)(1)
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:
(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

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 based on the discrepancy observed in 1 out of 4 Record of Client's/Residents Safeguarded Cash Resources and monies, which posed a personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Administrator reported they will conduct an all staff training regarding Title 22 regulation 80026 and proper management practices and documentation of the clients' safeguarded cash resouces. Proof of correction to be emailed to LPA by close of business on 6/6/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/30/2025 01:57 PM - It Cannot Be Edited


Created By: Janette Romero On 05/30/2025 at 01:21 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: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
85076(d)(1)
85076 Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 by no maintaing a two day supply of perishable foods for the clients, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2025
Plan of Correction
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Administrator reported facility staff will deliver more than a two-day supply of perishable foods for the clients later today (5/30/2025). A copies of receipt(s) along with a photograph of foods purchased today will be emailed to LPA by close of business on Monday, 6/2/2025.
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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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