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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800283
Report Date: 03/01/2024
Date Signed: 03/01/2024 12:40:00 PM

Document Has Been Signed on 03/01/2024 12:40 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: DATE:
03/01/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Program Manager, Steven HernendezTIME COMPLETED:
12:17 PM
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 At 10:15am on 03/01/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the day program to conduct a collateral visit for facility 425850083. LPA was joined by Quality Assurance Manager, Miguel Magana from Tri Counties Regional Center (TCRC). An interview was conducted of Client 1 (C1). Staff of Day Program, Momentum also joined the interview of C1 Those staff were, Program Manager, Carry Addrade, Case Manager, Yvette Arnold, and Program Manager, Steven Hernendez.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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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