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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700606
Report Date: 02/13/2024
Date Signed: 03/12/2024 04:32:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/12/2024 04:32 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:MOHAMMAD ESMAEL DARMANFACILITY TYPE:
772
ADDRESS:436 NORTH WHITE ROADTELEPHONE:
(408) 259-0760
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 16CENSUS: 16DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mohammad Esmael DarmanTIME COMPLETED:
04:31 PM
NARRATIVE
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This is an amended report from Annual Inspection conducted on 02/13/24 to remove LIC809D.

Licensing Program Analyst Steve Chang conducted an unannounced annual Inspection and met with program manager/administrator (ADM) Mohammad Esmael Darman.

Licensee, personal rights posters, and administrator certificate were observed at the main entrance.

LPA observed 8 staff and 16 residents in the facility. 5 resident files and 5 staff files were reviewed.

LPA toured the facility with ADM. There are 10 resident rooms including 4 single rooms and 6 shared rooms. Copy room/Break room, administrative office, manager office, staff offices, clinician office, living room (TV room), community room, laundry room, storage room, Med room and doctor office were observed in facility. Dinning room, 3 restrooms and kitchen were observed and inspected. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. Room temperature was observed at 70 degree F, and hot water temperature was observed at 118 degree F. The temperature of refrigerator was at 38 degree F, and the temperature of the freezer was at 0 degree F. Medication supplies were observed locked in the Med room. Med room was observed locked. Knives were observed locked in kitchen. Detergent supplies were observed locked in the storage room.

Fire extinguisher was serviced on 2/10/2024. The facility is equipped with fire alarm, smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine.

The facility's last emergency and fire drill was conducted on 2/5/2024.

No deficiency cited during today's visit.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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Document Has Been Signed on 02/13/2024 05:01 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/13/2024 at 03:41 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MOMENTUM FOR MENTAL HEALTH-FSP RESIDENTIAL
FACILITY NUMBER: 430700606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
81066(c)(10)

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81066 Personnel Records (c)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(10) A health screening as specified in Section 81065(g).

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Administrator stated the facility will submit a plan of correction by the POC due date.
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This requirement is not met as evidenced by:

Based on record review, the licensee did not comply with the section cited above in that 1 out of 5 staff was observed without health screening record, LIC503, which poses a potential health risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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