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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800477
Report Date: 07/26/2023
Date Signed: 07/28/2023 08:36:48 AM

Document Has Been Signed on 07/28/2023 08:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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: 4DATE:
07/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Edward Maldonado, Administrator/Program Manager, Arturo Arrevalo, Direct Support Professional/Caregiver, Lilia Guiterrez, Direct Support Professional/CaregiverTIME COMPLETED:
04:30 PM
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The Facility Evaluation Report for the required 1-Year Annual facility site inspection visit at Momentum Work, INC., Via Riviera was completed, signed by the facility Direct Support Professional, and final printed on 07/26/2023 by Licensing Program Analyst (LPA) Brian Phillips.

This continuation form is being produced due to an error in the transferring of the completed Inspection Tool into the Database used by the LPA (FAS CDSS).

On 07/26/2023, No deficiencies were cited, and exit interview was conducted, and a copy of the report was issued to the Administrator, Edward Maldonado.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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