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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202684
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:45:40 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/11/2022 02:45 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: 11DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Christine Rossi, ADMTIME COMPLETED:
12:20 PM
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Licensing Program Analyst Steve Chang conducted an Annual Inspection and met with Administrator (ADM) Christina Rossi. Upon arrival at facility, the front office staff took LPA body temperature and, and checked in LPA in the visitor log book. LPA observed COVID-19 posters in the facility. LPA observed screening station with hand sanitizer, masks, visitor log book at many places in facility. LPA observed staff wore the mask.

LPA toured the facility with ADM. Visiting room, front office, common area, offices, restrooms, medication room, group room, laundry room, conference rooms, client dinning room, and kitchens were observed and inspected. LPA observed the beds in the shared rooms were 6 feet apart. LPA observed not all the trash bins in the facility had the covers. ADM stated the facility will change the trash bins to have covers in 5 days. There were no posters of washing hands for 20 seconds by the sinks in restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds by the sinks in 5 days.

Fire extinguisher was serviced on 03/22/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. ADM stated all the staff are fully vaccinated and done with boosters.

ADM stated the facility has sufficient PPEs and sufficient food. The facility already submitted LIC9282, infection control plan..

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 provided to ADM..
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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