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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202684
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:52:31 PM

Document Has Been Signed on 08/17/2021 04:52 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 CRISIS RESIDENTIALFACILITY NUMBER:
435202684
ADMINISTRATOR:ALBERT CARRASCOFACILITY TYPE:
772
ADDRESS:101 JOSE FIGURESTELEPHONE:
(408) 254-6828
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 16CENSUS: 15DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Juan CooperTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Steve Chang conducted an Annual Inspection and met with senior manager/administrator (ADM) Juan Cooper. 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. LPA observed hand sanitizer at many places in facility. LPA observed staff wore the mask. Rosters of staff and residents are obtained.

ADM stated the current census is 15. LPA toured the facility inside out with ADM. There are 9 resident rooms including 2 single rooms and 7 shared rooms. LPA observed the beds in the shared rooms are 6 foot apart. ADM stated the break room was closed 2 weeks ago. ADM stated the TV room and library room are only allowed 2 people at one time. ADM stated the dinning room is only allowed 2 people at one time. ADM stated most residents pick up the meals or meals are delivered to the resident rooms. ADM stated the residents are only allowed to smoke outside the building. LPA observed not all the trash bins in the facility have the covers. ADM stated the facility will change the trash bins to have covers.

ADM stated the facility has sufficient PPEs and sufficient food. LPA discussed and reviewed LIC808 with ADM. ADM stated the facility follows the COVID protocol.

No citation were issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM..
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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