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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800477
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:46:31 PM

Document Has Been Signed on 07/07/2022 02:46 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. VIA RIVERIAFACILITY NUMBER:
425800477
ADMINISTRATOR:EDWARD MALDONADOFACILITY TYPE:
735
ADDRESS:5707 VIA RIVIERATELEPHONE:
(805) 934-1608
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 5CENSUS: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edward Maldonado/AdministratorTIME COMPLETED:
02:00 PM
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 At 12:00pm on 07/07/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced annual infection control inspection. LPA asked direct care staff to call house administrator Edward Maldonado to come the facility for the infection control inspection. Mr. Maldonado arrived shortly after (12:18pm).
This facility is 4 bedroom, 2 bath room, living room kitchen, with garage that is used as a laundry area, extra food storage area, PPE storage, linin storage and emergency water storage. There is a back yard for clients to be outside and a covered area for shade. LPA observed ample amount of PPE in the garage storage area. Provider Information Notices are easily accessible and presented to LPA upon request during inspection process. LPA and Administrator took a cursory tour of the facility. LPA observed 7 days of perishable and 2 days of non-perishable foods. LPA did not observe and hazards during the tour that would place the clients in care in any danger at the time of the walk through. .

LPA and Administrator conducted the infection control module and did not occur any deficiencies during the module.

Exit interview, report signed and copy emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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