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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700606
Report Date: 02/22/2022
Date Signed: 02/22/2022 04:14:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/22/2022 04:14 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MOMENTUM FOR MENTAL HEALTH-FSP RESIDENTIALFACILITY NUMBER:
430700606
ADMINISTRATOR:LAUREN MCCHESNEYFACILITY TYPE:
772
ADDRESS:436 NORTH WHITE ROADTELEPHONE:
(408) 259-0760
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 16CENSUS: 10DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Mohammad Esmael DarmanTIME COMPLETED:
01:38 PM
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Licensing Program Analyst Steve Chang conducted an Annual Inspection and met with program manager/administrator (ADM)Mohammad Esmael Darman and assistant program manager Nancy Maldonado. Upon arrival at facility, the front office staff took LPA body temperature and asked the infection control questionnaires, and checked in LPA in the visitor log book. LPA observed COVID-19 posters in the facility. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. LPA observed staff wore the mask. Rosters of staff and residents are obtained.

ADM stated the current census is 10. LPA toured the facility inside out with ADM. There are 10 resident rooms including 4 single rooms and 6 shared rooms. LPA observed the beds in the shared rooms were 6 foot apart. Break room, Admin office, living room, community room, storage room, Med room, staff offices were observed. Dinning room, 3 restrooms and kitchen were observed and inspected. ADM stated the means for residents were served at different time to avoid all residents have the meals at the same time. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. All trash cans were observed with covers. Not all sinks with washing hands poster. ADM stated the facility will fix the issue in 2 days. All paper towels were observed either with dispenser or with holders. ADM stated the residents are only allowed to smoke outside the building. Room temperature was observed at 70 degree F, and hot water temperature was observed at 115 degree F.PPE supplies were observed sufficient. ADM stated all staff and residents were fully vaccinated and done with booster.

No citation were issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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