425801987-1-31-2023-29-AS-JOLN-CNLR3G-20230131113954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801987
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:40:23 AM

Document Has Been Signed on 01/31/2023 11:40 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. ROSE		FACILITY NUMBER:	425801987
ADMINISTRATOR:	STEVEN ALMAGUER		FACILITY TYPE:	735
ADDRESS:	434 E. ROSE AVENUE		TELEPHONE:	(805) 614-0967
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 4		CENSUS: 4	DATE:	01/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Steven Almaguer, Administrator		TIME COMPLETED:	11:50 AM

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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 01/31/2023 around 9:50 AM. LPA met with Steven Almaguer, Administrator around 10:15 and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Administrator. The facility has an entry point at the side door where everyone entering completes a sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff will screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility and on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

The Director of Residential is in charge of infection control and provides training and education to staff, residents and visitors.

Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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. ROSE	FACILITY NUMBER: 425801987
	VISIT DATE: 01/31/2023

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Staff will use full PPE with N95 masks and face shields when around with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single rooms and they are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies.

Director of Residential will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff and resident records are kept in a locked cabinet. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. Administrator Certificate is valid. Fire extinguishers were charged and inspected annually. The facility has working smoke and carbon Monoxide detectors throughout the facility.

At approximately 11:00 am, LPA reviewed Guardian/Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that one staff is fingerprint cleared but not associated to the facility.

All infection control protocols are implemented and are being followed.

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

A civil penalty for $500 was assessed.

Exit interview completed and copy of report, appeal rights, and civil penalty was printed and issued to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2023 11:40 AM - It Cannot Be Edited

Created By: Jeannette Olson On 01/31/2023 at 11:17 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. ROSE	FACILITY NUMBER: 425801987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one staff is not associated which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/01/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove staff from the schedule until Staff 1 is associated and submit proof to LPA that staff was associated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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