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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800477
Report Date: 06/06/2025
Date Signed: 09/16/2025 01:53:01 PM

Document Has Been Signed on 09/16/2025 01:53 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/
DIRECTOR:		EDWARD MALDONADOFACILITY TYPE:
735
ADDRESS:5707 VIA RIVIERATELEPHONE:
(805) 934-1608
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 5CENSUS: 5DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:29 AM
MET WITH:House Manger, Alan VacaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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 At 7:30am on 06/06/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced annual facility inspection. LPA asked direct care staff to call house House Manager, Alan Vaca to come the facility for the facility annual inspection. LPA met with House Manager, Alan Vaca announced who he is and the reason for the visit.

Administrator and LPA took a cursory tour of the facility. This facility is 4 bedroom, 2 bath room, living room kitchen, with a laundry area in the garage and extra food storage area, PPE storage, There is a living room and a large table/island separating the kitchen from the living room. There is a staff office and meeting room off the living room. Medications and files are locked and located in filing cabinets in the staff office/meeting room. LPA noted linin storage in the hallway closet. There is a back yard for clients to be outside and a covered area for shade. LPA observed 7 days of perishable and 2 days of non-perishable foods. LPA observed a working fire extinguisher under the kitchen sink. LPA noted that each client room had furniture and linin within regulation requirements. LPA noted that both bathroom has paper towels and liquid soap. LPA noted that the facility was clean and in good repair and all hallways and exits were free and clear of obstacles. LPA reviewed Emergency Disaster Plan, Infection Control Plan, Centrally Stored Medication Records and Staff and Client files with no issues. At this time there were no violations or citations issued as a result of the annual facility physical inspection.

LPA and Administrator conducted the full review of annual care tools modules. LPA noted that there were no violations or citations as a result of the annual facility inspection.

Exit interview, report signed and copy provided. .
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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