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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802113
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:34:41 PM

Document Has Been Signed on 09/29/2022 04:34 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. MARSALAFACILITY NUMBER:
425802113
ADMINISTRATOR:HOLCOMBE, PAMELAFACILITY TYPE:
735
ADDRESS:1424 W. MARSALA AVE.TELEPHONE:
(805) 349-7908
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 4DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Edward Maldonado, Backup AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management visit to address deficiencies. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa. LPA's and QAS arrived at 2pm and Edward Maldonado, Backup Administrator arrived to the facility around 2:30 PM. LPA and QAS and explained the purpose of the visit..

On 9/13/22 CCL was informed that the facility did not follow the COVID Outbreak Protocols. A staff tested positive for COVID on 8/27/22 and the facility did not notify CCL. The facility also did not follow Local Public Health orders or direction. On 7/19/22 LPA emailed and spoke with the Executive Director of Momentum and explained CCL policies for positive staff after it was discovered other facilities weren’t following the protocol.

LPA and QAS took a physical Plant tour of the inside and outside of the facility. LPA and QAS observed multiple physical plant deficiencies including:
At 2:40 PM LPA and QAS observed garage refrigerator handle to be broken
At 2:45 PM LPA and QAS observed towel racks in 2 bathrooms broken
At 2:50 PM LPA and QAS observed a light not working in the bathroom
At 3PM LPA and QAS observed chemicals unsecured under the sink
3:05 PM LPA and QAS observed multiple broken chairs and a broken umbrella in the backyard.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's report and appeal rights were reviewed and emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/29/2022 04:34 PM - It Cannot Be Edited


Created By: Jeannette Olson On 09/29/2022 at 03:48 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. MARSALA
FACILITY NUMBER: 425802113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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Administrator immediately removed hazardous items and locked them up. Administrator agreed to hold training on the importance of keeping hazardous materials locked up and submit training records to CCL with staff's full name, date trained and signature to CCL by 9/30/22.
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Based on observation, the licensee did not comply with the section cited above as there were chemicals unlocked under the kitchen sink, accessible to clients, which poses an immediate health and safety risk to residents in care.
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Type A
09/30/2022
Section Cited
CCR80087(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 is not met as evidenced by:
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Administrator agreed to throw away broken furniture immediately and submit a plan to address the multiple Buildings and Grounds deficiencies and submit the plan to CCL by 9/30/22.
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Based on observation, the licensee did not comply with the section cited above as there were multiple items broken items including towel racks, a light and multiple broken chairs which poses an immediate 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/29/2022 04:34 PM - It Cannot Be Edited


Created By: Jeannette Olson On 09/29/2022 at 04:01 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. MARSALA
FACILITY NUMBER: 425802113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
80061(b)(1)

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80061 Reporting Requirements (b) Upon the occurrence...(1)...a report shall be made to the licensing agency....next working day....a written report containing the information specified... shall be submitted to the licensing agency within seven days following the occurrence...
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The Administrator agreed to do the following:
Review Regulation 80061 and submit a Statement of Understanding, detailing how the licensee plans to maintain voluntary compliance. Administrator agreed to submit statement no later than 10/10/22.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the facility did not report a positive COVID case to CCL, which poses 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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