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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005941
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:07:53 PM

Document Has Been Signed on 04/15/2022 01:07 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HORWITZ FAMILY HOUSEFACILITY NUMBER:
306005941
ADMINISTRATOR:MCDONALD, LISAFACILITY TYPE:
735
ADDRESS:1621 PORTOLA AVENUETELEPHONE:
(818) 782-2211
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 6DATE:
04/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Yvette DoranTIME COMPLETED:
01:30 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
Licensing Program Analyst Michelle Reed arrived at the facility to conduct an Annual visit. Upon arrival, LPA met with Gabriel Negrete and Brenice Betancourt. Administrator Yvette Doran was contacted and arrived a short time after LPA. During the visit, LPA also conducted this Case Management visit regarding the facility License.

On 10/6/21, during a complaint visit, LPA noted that the facility Corporation had been changed and that UNITED CEREBRAL PALSY/SPASTIC CHILDREN'S ET AL is no longer the Licensee. The new Licensee is Momentum. At that time LPA informed Momentum Chief Operations Officer Amy Simones that a new License would need to be obtained. As of today's date, no proof of application has been received.

See LIC809D for cited deficiency.

An exit interview was conducted, appeal rights discussed and a copy of this report was provided to Yvette Doran.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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 04/15/2022 01:07 PM - It Cannot Be Edited


Created By: Michelle Reed On 04/15/2022 at 12:58 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HORWITZ FAMILY HOUSE
FACILITY NUMBER: 306005941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited
CCR
80034(a)(2)

1
2
3
4
5
6
7
Submission of New Application-A licensee shall file a new application as required by Section 80018 whenever there is any change of licensee.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Corporation Momentum will apply for a new License within 14 days and provide proof to LPA Reed that the application was submitted. If an application is not submitted within 15 days civil penalties will be assessed.
8
9
10
11
12
13
14
The Licensee(Corporation) has changed for this facility and a new license has not been submitted.

This poses an immediate health and safety risk to residents in care as the facility is not Licensed at this time.
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:Sheila Santos
LICENSING EVALUATOR NAME:Michelle Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


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