425801613-12-13-2023-29-AS-JOLN-CYGUYV-20231213150033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801613
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:00:53 PM

Document Has Been Signed on 12/13/2023 03:00 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 TERRACE		FACILITY NUMBER:	425801613
ADMINISTRATOR:	EDWARD MALDONADO		FACILITY TYPE:	735
ADDRESS:	824 EAST SLOAN TERRACE		TELEPHONE:	(805) 937-0360
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 4		CENSUS: 4	DATE:	12/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Kari Bowron, Director of Residental Services		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual inspection. LPA met with Director of Residential Services and explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored and locked in a cabinet in the garage, inaccessible to clients. Knives are stored in the garage.

Common areas: Living and dining room furniture were observed to be in good condition. At 12:00 p.m., carbon monoxide detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguishers were charged and serviced 1/10/2023.

The backyard has an umbrella for shade and is equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the laundry room.

Restrooms: The three client restrooms was clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels. Around 11:45 a.m., the hot water temperature measured in the clients bathroom at 120.2 degrees Fahrenheit.

Bedrooms: There are four (4) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: LPA reviewed client and staff records at 10:30 a.m. LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plan.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 TERRACE	FACILITY NUMBER: 425801613
	VISIT DATE: 12/13/2023

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4i home. The last disaster drill was conducted on 10/8/23.

Medications: Medications review began around 12:45 p.m. medications are centrally stored and locked in a cabinet in the office. Medications are labeled and checked for expiration dates. LPA advised the Director to ensure that all the necessary information is properly documented on the CSMAR.

Infection Control: The facility has an infection control plan. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol could be improved. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA interviewed 1 resident around 12:15pm and 1 staff at 1:40 pm. The other 3 clients and staff were at program or in the community and unable to be interviewed during the visit.

Exit interview conducted. A copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC809 (FAS) - (06/04)

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