425801613-3-29-2023-29-AS-JOLN-CQDMY2-20230329100045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801613
Report Date: 03/29/2023
Date Signed: 03/29/2023 10:01:56 AM

Document Has Been Signed on 03/29/2023 10:01 AM - 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:	03/29/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Edward Maldonado, Administrator		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent Case Management visit to issue final findings on an Incident that happened on or around 1/1/23. LPA conducted the investigation with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa and interviewed clients, and staff on 1/11/23, 2/17/23, 3/8/23, 3/13/23, 3/27/23, and 3/28/23. LPA and QAS met with Administrator and Director of Residential Services 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. Interviews with Staff revealed C1 had a bruise most staff noticed on 1/3/23. One AM staff stated they noticed a small mark on C1’s eye on 1/2/23 and talked to the NOC shift about it, and NOC said they had already reported it to the Administrator. The staff later found out that was not true and realized they should have reported it sooner. When LPA interviewed the NOC staff, they stated they had informed the Administrator by phone and put the observation in the notes. LPA reviewed C1’s ID notes from 12/26/22 through 1/10/23, and observed there were no notes about a bruise under NOC shift for 1/1/23 through 1/3/23. On 1/3/23 during the 8am-4pm shift there is a note about staff observing a bruise and C1 stating it is from a staff throwing a water bottle and hitting C1. All staff interviewed stated C1 makes up stories, but most staff stated those stories change often, but this story stayed consistent. When asked, most staff said they believed the story due to it staying the same every time repeated. When asked about S1, one staff stated they “had anger issues, you can see it in their eyes”, and a second staff stated they witnessed S1 “cuss and yell at clients”. Administrator stated after hearing about the incident they put S1 on administrative leave while they investigated. Administrator said due to C1’s history of making up stories and C1 repeatedly changing the date the incident happened and adding things to the story, they allowed S1 to come back to work but at different facility. Continued on 809-C (pg2)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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: 03/29/2023

NARRATIVE

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LPA and QAS interviewed Client 2 (C2) who stated they witnessed Staff 1 drop a TV on C1’s legs on 12/31/23. C2 stated they saw S1 was taking C1’s TV to the garage and dropped it on C1’s legs. C2 was able to describe the TV as being a TV with the DVD combined, about 13 inches, and provided a detailed account of the incident. C1 asked S1 to stop several times. S1 went back into C1’s room, closed the door, and C2 stated they heard C1 screaming and asking S1 to stop several times. C2 stated another staff “went over there and stopped (S1)". C2 stated S1 asked them if they saw anything, and then S1 told C2 "you didn’t see anything". C2 stated when they heard about the water bottle incident, at first they did not believe C1 but then they observed the bruising on C1’s face, believed the story, and called the Administrator on 1/3/23 to tell them about the TV incident. When asked about the incident Administrator stated they never heard of this and was not aware of an incident with a TV between S1 and C1.

Staff interviewed stated on 12/31/23 and around 3:40 PM C1 was in the living room watching TV when S1 told them to go to their room. Staff stated it didn’t make sense and was strange because C1 wasn’t doing anything wrong. Eventually C1 went to their room and S1 followed, closed the door. 6-10 minutes later, staff heard C1 crying, goes to the room, opens the door and observes C1 and S1 cussing at each other. QAS asked what words were used, staff responded the F word. Staff stated S1 uses the F word with the clients in the home. S1 is very aggressive, yells, screams, and uses the F word and speaks very badly to the clients. Staff then said they asked what was going on and S1 said nothing, everything is ok. Staff stated C1 seemed very agitated, scared, and was crying a lot. Staff said they came back 3-5 minutes later because C1 is still crying and sees C1 and S1 hugging/embracing but didn’t hear anything that was said. Staff said that S1 stayed in there for a few more minutes with the door closed and left.

Facility HR stated they conducted an internal investigation, and learned C1’s TV and radio were removed from C1’s room, allegedly as punishment for C1’s behaviors. After investigation, HR determined staff removed the TV and radio because they were broken. LPA and QAS learned there were no previous allegations made against S1.
LPA and QAS interviewed S1, who stated that they removed the radio after C1 broke the antenna because it was a hazard, took it the garage for approximately 5 minutes, removed the antenna, brought it back and it still worked. S1 stated they never removed the TV from C1’s room, and denied hitting C1 with the TV or throwing a water bottle at C1. S1 also denied being in C1’s room on that weekend. S1 stated, “I don’t know how they got that. I give them their meds and their breakfast and then just sit in the back room and read a book or clean.” Continued on 809-C (Pg 3)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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: 03/29/2023

NARRATIVE

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LPA and QAS interviewed Client 3 (C3) and asked if they remembered an incident in January and C3 said, “oh yeah (C1) got hurt” When asked what they remember they said, “I think I heard something, screaming but not sure who was hitting (C1) though.” LPA and QAS asked if staff were nice and C3 said “most are nice.” LPA asked if any staff weren’t nice? C3 did not respond. QAS asked about different staff that worked at the facility and to give them a thumbs up for good, thumbs sideways for ok, and thumbs down for bad. C3 gave a thumbs up for all staff but a thumbs sideways/ok for Staff 1. When asked why C3 said “sometimes…” looked uncomfortable and stopped talking.

Clients interviewed stated they felt “safer” with S1 no longer working at the facility. LPA and QAS interviewed Client 1 again on 3/13/23 about the incident and C1 said, “(S1) was in my room and closed the door and hit my eye badly with a full water bottle.” When asked if there was another incident with S1, C1 stated, “(S1) dropped a TV on my leg, left a big bruise.” LPA asked client to take them to their room to show them the TV. Client said it was in the garage. Staff got the TV out of the garage and C1 put a DVD in it and was able to play a movie. LPA observed the top right corner to have a loose panel. LPA and QAS interviewed Administrator who stated the TV was in the garage off and on due to C1 requesting it to be removed and because it was broken. Administrator stated C1 will ask for it back or ask for staff to put it in the garage depending on their mood. Administrator also stated sometimes C1 picks at it and some staff remove it for C1’s safety. LPA asked why they haven’t taped the broken piece. Administrator stated they have taped it but C1 picks at the tape so they are waiting for the family to replace it. LPA did not observe the TV to have any tape or tape residue on the top right corner on 3/13/23 and also did not observe the TV to be in C1’s room on 1/11/23.

After conducting staff interviews LPA and QAS observed the schedule given wasn’t accurate/updated. LPA and QAS requested time sheets for 12/31/22-1/1/23. 4 clients were reported to be in the home these days and time cards reflect there was only one staff present on 12/31/22 from 4pm-8pm and 9am-12am on 1/1/23.

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

Exit interview conducted, copy of report and appeal rights were printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/29/2023 10:01 AM - It Cannot Be Edited

Created By: Jeannette Olson On 03/29/2023 at 07:35 AM

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: 03/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/30/2023 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to schedule a training with all staff on personal rights and send the date to CCL by 3/30/23. Administrator also agreed to send a copy of the training to CCL with name, dates, topics covered and staff signatures.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above when S1 did not treat clients with dignity, which posed an immediate health and safety/personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 04/05/2023 Section Cited CCR85065.5(a)(1)	1 2 3 4 5 6 7	85065.5(a)(1) Day Staff-Client Ratio (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a new schedule reflecting Regional Center staffing ratios by 4/5/23.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above when Regional Center staffing ratios were not maintained, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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