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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801613
Report Date: 01/11/2023
Date Signed: 01/11/2023 02:00:16 PM

Document Has Been Signed on 01/11/2023 02:00 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 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:
01/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ed Maldonado, AdministratorTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to investigate 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 Ed Maldonado, Administrator and explained the purpose of the visit.

CCL received an incident report on 1/04/23 stating that on 1/03/23 staff noticed Client 1 (C1) had bruising on left inner part of their eye and when asked what happened C1 stated Staff 1 (S1) threw a water bottle at them on 1/1/23.

LPA and QAS toured the facility and interviewed Administrator, Staff and Clients regarding the incident. LPA and QAS requested relevant documents. At this time, further investigation is needed. LPA will follow up at a later date to continue the investigation.

Around 11:15 AM LPA and QAS observed one light bulb in the bathroom fixture with 2 light bulbs out.
Around 11:20 AM LPA and QAS observed Client 1's dresser to have a missing handle and their blinds to be dusty.
Around 1:15 PM LPA and QAS observed Client 2's dresser to have used Kleenex bunched up.
Around 1:30 PM LPA and QAS observed Client 3's bathtub to have soap buildup and a rag to be partially black. The sink was observed to have hair in it and around it.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted and a copy of the report emailed to the administrator/licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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Document Has Been Signed on 01/11/2023 02:00 PM - It Cannot Be Edited


Created By: Jeannette Olson On 01/11/2023 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOMENTUM WORK, INC. SLOAN TERRACE
FACILITY NUMBER: 425801613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidenced by:
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Administrator agreed to clean the facility and put a new handle on the dresser or replace it and send pictures to CCL by 1/18/23.
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Based on observation, the licensee did not comply with the section cited above when the facility was not clean or in good repair, which posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
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