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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
430700606
Report Date:
07/03/2024
Date Signed:
07/03/2024 04:20:00 PM
Document Has Been Signed on
07/03/2024 04:20 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 RESIDENTIAL
FACILITY NUMBER:
430700606
ADMINISTRATOR/
DIRECTOR:
MOHAMMAD ESMAEL DARMAN
FACILITY TYPE:
772
ADDRESS:
436 NORTH WHITE ROAD
TELEPHONE:
(408) 259-0760
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95127
CAPACITY:
16
CENSUS:
13
DATE:
07/03/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:
Mohammad Esmael Darman
TIME VISIT/
INSPECTION COMPLETED:
01:39 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Program Manager Mohammad Esmael Darman (PM).
LPA interviewed Program Manager (PM) and resident R1.
LPA requested residents R1 and R2 physician reports and appraisal/needs and service plans.
PM stated the facility completed the internal investigation and the facility was unable to find the evidence to prove that the allegation did or did not occur.
R1 still stays at the facility and R2 already moved out to another facility.
LPA tried to contact staff S1 on the phone but failed to contact S1.
This case needs further investigation.
Exit interview was conducted with PM. The report was provided to PM. A copy of the report was provided to PM.
SUPERVISORS NAME
:
Romeo Manzano
LICENSING EVALUATOR NAME
:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/03/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/03/2024
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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