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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801613
Report Date: 12/06/2024
Date Signed: 12/10/2024 07:12:36 PM

Document Has Been Signed on 12/10/2024 07:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOMENTUM WORK, INC. SLOAN TERRACEFACILITY NUMBER:
425801613
ADMINISTRATOR/
DIRECTOR:
EDWARD MALDONADOFACILITY TYPE:
735
ADDRESS:824 EAST SLOAN TERRACETELEPHONE:
(805) 937-0360
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 4CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Edward Madldonado,, Director TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Erika Miller arrived unannounced to conduct a one year required annual inspection. LPA met with Edward Maldonado, administrator and explained the reason for the visit.

LPA toured the physical 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. Knives are stored in locked pantry.

Common areas: Living and dining room furniture were observed to be in good condition. The carbon monoxide detector and smoke detector were tested and operational at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 1/9/24.

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 bathrooms were sufficiently stocked with soap and paper towels and in working condition. Around 12.26 p.m., the hot water temperature measured in the shared bathroom at 115.8 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 four (4) client files for 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: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOMENTUM WORK, INC. SLOAN TERRACE
FACILITY NUMBER: 425801613
VISIT DATE: 12/06/2024
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LPA reviewed five (5) staff files for personnel records, health screening, and current first aid certification. All files were complete.

Medications: Medications are centrally stored and locked in a cabinet in the living area. No medications were expired.

Exit interview conducted. A copy of the report was printed for Administrator

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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