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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850008
Report Date: 10/29/2022
Date Signed: 10/29/2022 10:30:27 AM

Document Has Been Signed on 10/29/2022 10:30 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. LAKESIDEFACILITY NUMBER:
425850008
ADMINISTRATOR:STEVEN ALMAGUERFACILITY TYPE:
735
ADDRESS:423 MONTEREY RDTELEPHONE:
(805) 739-0451
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
10/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Steven Almature/AdministraterTIME COMPLETED:
11:00 AM
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 At 8:45am on 10/29/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an annual infection control inspection. LPA met with staff 1, Jennifer Ramirez (S1). S1 properly screened LPA for COVID-19 protocols. S1 called Administrator Steven Almaguer to come to the facility for the annual infection control inspection.
Administrator arrived and took LPA on a cursory tour of the facility. This facility is a 4 bedroom 2 bathroom with kitchen, dining room, living room and back office/activity room there is an outside area in the back, side and front for clients to utilized for outdoor activities and a swing chair with shade. LPA observed no obstruction to exits, doors and observed self latching gates at the front and side of the facility. LPA observed the fire extinguisher to be in the green functioning and currently tagged. There are working fire alarms in each room and a carbon monoxide/fire detector combination in the facility hall roof. LPA observed at least a 2-day supply of perishables and at least a 7-day supply of non-perishable foods. LPA observed at least a 30 day supply of PPE on hand in the garage. LPA observed soap and paper towel dispensers in each bathroom. LPA noted that the water temperature is within regulation range not exceeding *120*f. LPA noted that the facility was clean and in good repair with no noticeable violations on the cursory tour.
Administrator, Program Director, Pam Holcolmbe, and LPA conducted the infection control portion of the annual inspection. LPA noted that there were not violations. There were no violation or deficiencies cited on this annual infection control visit.

Exit interview, report singed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2022
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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