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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801613
Report Date: 03/13/2023
Date Signed: 03/13/2023 04:34:30 PM

Document Has Been Signed on 03/13/2023 04:34 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. SLOAN TERRACEFACILITY NUMBER:
425801613
ADMINISTRATOR:EDWARD MALDONADOFACILITY TYPE:
735
ADDRESS:824 EAST SLOAN TERRACETELEPHONE:
(805) 937-0360
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 4CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Fernando Rodriguez, StaffTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Olson conducted a follow up Case Management - Incident visit to contnue the investigation about an incident the facility self reported. LPA was accompanied by Vince Figueroa, Quality Assurance Specialist (QAS) for Tri-Counties Regional Center. LPA and QAS met with Staff and explained the purpose of the visit.

LPA and QAS toured the facility and interviewed Clients regarding the incident. LPA and QAS requested a new schedule. At this time, further investigation is needed. LPA will follow up at a later date to continue the investigation.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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