<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602707
Report Date: 04/17/2023
Date Signed: 04/17/2023 12:25:32 PM

Document Has Been Signed on 04/17/2023 12:25 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:
04/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:William Morries Lathe, CaregiverTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/17/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20230414102154. LPA met with Caregiver, William Morries Lathe who was informed of the purpose of the visit.

At the time of initial entry, Caregiver William refused LPA entry and asked LPA if Administrator was notified before the visit. LPA informed William that licensing agency has inspection authority and an immediate fine will be assessed if not granted entry. William refused LPA entry into the facility until Administrator is notified. LPA waited for a long while before LPA was granted entry into the facility. LPA Nwogene completed an LIC421IM and assessed the immediate $500 fine.


An exit interview was conducted were this report was discussed with Administrator, Chris Warner over the phone and a copy provided to William Morries Lathe along with copies of the LIC809-D, LIC421IM, and Appeal Rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/17/2023 12:25 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 04/17/2023 at 12:00 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: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2023
Section Cited
CCR
80044(a)

1
2
3
4
5
6
7
80044 Inspection Authority of the Licensing Agency (a) The licensing agency shall have the inspection authority..This requirement was not met by:
1
2
3
4
5
6
7
Licensee agrees to review the regulation with staff and submit proof of such to LPA by POC date 4/18/2023.
8
9
10
11
12
13
14
Based on LPA observation, the caregiver did not allow entry initially for LPA to inspect. This presents an immediate health and safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Deborah Mullen
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2