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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850008
Report Date: 11/04/2025
Date Signed: 11/04/2025 11:53:57 AM

Document Has Been Signed on 11/04/2025 11:53 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/
DIRECTOR:		EDWARD MALDONADOFACILITY TYPE:
735
ADDRESS:423 MONTEREY RDTELEPHONE:
(805) 934-2600
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 3DATE:
11/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator, Edward MaldonadoTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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 At 8:00am on 11/04/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to a Serious Incident Report (SIR) of an incident that occurred at the facility on 10/29/2025 of alleged staff abuse of a client.
LPA conducted staff interviews of 6 out of 6 staff present, and conducted an in person interview of Client 1 (C1). LPA was able to ascertain that C1 was safe and in good health. In interview with C1, C1 stated that staff "smooched" pillow on C1's face, C1 stated that it did not hurt. C1 stated that Staff (S5) wouldn't listen to C1, was the reason that S5 smooched pillow on C1's face. C1 stated that "S5 dropped C1's tablet on the ground, and C5 was going to pay for that." C1 stated that the tablet was not broken or hurt. In interview with Staff 1 (S1) stated that they had been working with S5 for about 3 years and approximately 1.5 years as a direct support to C1 with S5 at Adult Day Program. S1 stated that S5 was exceptional with S1 and has never witnessed any negative interactions between C1 and S5. S1 stated that they think that S5 was not capable of doing anything negative to C1. LPA noted that S2, S3, and S4 had no knowledge of the details of the incident that occurred on 10/29/2025. S2, S3, and S4 stated that they have never witnessed S5 do anything negative to any of the clients. LPA conducted an interview with facility administrator, Edward Maladonado, who stated, C1 and S5 had worked together at the Adult Day Program (ADP) for several years as a one on one. Administrator stated that S5 is an excellent employee and has developed a positive relationship with C1 over the years at the ADP. Administrator that they are currently investigating the allegations to the SIR and S5 is currently on administrative leave. Administrator provided training documents for S5. LPA will require more time to conduct interviews and may return at a later date to address the incident that occurred on 10/29/2025.
Exit interview, report read, and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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