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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800283
Report Date: 06/21/2023
Date Signed: 06/21/2023 04:56:46 PM

Document Has Been Signed on 06/21/2023 04:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOMENTUM WORK, INC. SANTA MARIA DAY PROGRAMFACILITY NUMBER:
425800283
ADMINISTRATOR:MARIA PRINCEFACILITY TYPE:
775
ADDRESS:3070 SKYWAY DR STE 104 & 105TELEPHONE:
(805) 739-0451
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 105CENSUS: 81DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Prince, Administrator and Judy Linares, Executive DirectorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Olson arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. LPA met with Administrator and Executive Director (over the phone) and explained the reason for the visit. The program currently operates from 8:00 a.m. to 4:00 p.m.

Common Activity Space: The facility is a single-story structure with a conference room, offices, relaxing/multipurpose room, bead room, three (3) bathrooms, and a large open program area. LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. Carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed fire extinguishers throughout the facility, which were last serviced 01/10/2023.

Activities: Activities are both designed for individual and as a group. Some consumers do day outings.

Food Service: Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. At 12:19 p.m., water temperature in the restroom was measured at 110.9 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Record Review: Around 12:30 p.m. a review of facility files was initiated. LPA obtained Client Roster and Staff Roster. LPA reviewed five (5) of (81) Client Files. LPA reviewed three (3) of (55) staff files. All staff files were complete.

Medications: Medications are centrally stored and locked in a cabinet in an office. Medications are labeled and checked for expiration dates. Medications could use better documentation on the centrally stored medications and destruction record.

Report will continue on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOMENTUM WORK, INC. SANTA MARIA DAY PROGRAM
FACILITY NUMBER: 425800283
VISIT DATE: 06/21/2023
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Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Interview: During today's visit, the LPA interviewed four (4) staff and four (4) consumers. No immediate concerns voiced at this time.

Exit interview conducted and copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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