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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801987
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:50:00 AM

Document Has Been Signed on 04/13/2023 10:50 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. ROSEFACILITY NUMBER:
425801987
ADMINISTRATOR:STEVEN ALMAGUERFACILITY TYPE:
735
ADDRESS:434 E. ROSE AVENUETELEPHONE:
(805) 614-0967
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 4CENSUS: 4DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Steven Almaguer, AdministratorTIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management- Incident visit to the facility above. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa. LPA and QAS met with Administrator and explained the purpose of the visit.

CCL received an incident report on 04/05/23 stating that on 04/03/23 HR received a letter from a Staff 1 with allegations of staff turning on the vacuum cleaner (noise) to keep Client 1 (C1) in their room. Staff 1 also wrote that staff working with C1 leaves them in dirty soiled pull ups. An addendum was sent on 04/07/23 stating that allegations against staff was substantiated and 2 staff were let go and dismissed. The new Incident report also stated staff will review APS mandated reporting and supervision will be supervised more stringently with unannounced visits from management.

Interview with Administrator revealed all staff will be trained on mandated reporting and personal rights for 2 hours on 4/17/23.

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: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 10:50 AM - It Cannot Be Edited


Created By: Jeannette Olson On 04/13/2023 at 07:42 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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
80072(a)(1)

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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:
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Administrator agreed to schedule a training with all staff on personal rights and send the date to CCL by 4/14/23. Administrator also agreed to send a copy of the training to CCL with name, dates, topics covered and staff signatures.
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Based on interviews and record review, the licensee did not comply with the section cited above when Staff did not treat clients with dignity, which posed an immediate health and safety/personal rights 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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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