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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801987
Report Date: 03/19/2025
Date Signed: 04/04/2025 03:24:55 PM

Document Has Been Signed on 04/04/2025 03:24 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. ROSEFACILITY NUMBER:
425801987
ADMINISTRATOR/
DIRECTOR:		JOSEFINA SARABIAFACILITY TYPE:
735
ADDRESS:434 E. ROSE AVENUETELEPHONE:
(805) 614-0967
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 4CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Josie SarabiaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Amended Version on 4/4/25. Signature was not recorded for original document. Licensing Program Analyst (LPA) Rankin conducted a required unannounced 1 year annual visit to the facility above on 03/19/2025 around 9:05 AM. LPA met with Josie Sarabia Administrator explained the purpose of the visit.
A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environmental Safety: The facility has 4 client bedrooms and 3 bathrooms currently occupying 4 clients. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors, these alarms were tested and were working at time of visit. The lighting and lamps are sufficient for the use of the facility and for client comfort. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to clients locked in the garage and hall closet. The facility has sufficient space inside and outside for activities and visiting.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance.

Clients Records & Incident Reports: The facility keeps separate files on each client confidential. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID, TB results, Personal Rights, and Safeguard for personal property and valuables, Emergency contact forms, and Appraisal Needs and Services plans (ANS) are done and completed. Facility does submit incident reports to the department when required.

Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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. ROSE
FACILITY NUMBER: 425801987
VISIT DATE: 03/19/2025
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Ammeded on 4/4/25 for signature addition.
Clients Rights - All required postings were posted in the common area of the facility, Personal rights and Persons with disabilities as well as the CCL Complaint poster. Internet is provided to each client and each client is given confidentiality and privacy.

Food Service: The facility kitchen is clean, safe, and sanitary. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the clients want them. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all client in care are centrally stored. LPA reviewed a sampling of medications and records. No medication labels were altered. Medication is given as prescribed with physician’s orders which are kept with the client’s records.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected January 2025. Emergency exits and telephone numbers were posted.

LPA was unable to complete inspection for training records and will return at another time.

Exit interview conducted and copy of report printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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