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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202684
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:55:57 PM

Document Has Been Signed on 08/27/2024 04:55 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MOMENTUM FOR MENTAL CRISIS RESIDENTIALFACILITY NUMBER:
435202684
ADMINISTRATOR/
DIRECTOR:
CHRISTINE ROSSIFACILITY TYPE:
772
ADDRESS:101 JOSE FIGURESTELEPHONE:
(408) 254-6828
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 16CENSUS: 14DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Lisa GiulianiTIME VISIT/
INSPECTION COMPLETED:
04:28 PM
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Licensing Program Analyst Steve Chang conducted an unannounced annual Inspection and met with Program Manger Quentin Brooks (PM) and Licensing and Regulations Manager Lisa Giuliani (LRM).

LPA toured the facility inside and out with PM and LRM. Visiting room, front office, common area, offices, restrooms, medication room, group room, library, laundry room, medications, activity room, cleaning supplies room, conference rooms, storage rooms, client dinning room, 7 resident shared rooms and 2 resident single rooms, and kitchens were inspected. Medications room, cleaning supplies room, laundry room, knives closet were observed locked. Bars and non skid floors were observed in the bathrooms.

Two days perishable food supplies and Seven days non perishable food supplies were observed sufficient. The temperature of the freezer was observed at -6 degree F and the temperature of the refrigerator was observed at 42 degree F.

PM stated the facility has emergency generator system. First aid box was observed in the facility. Hot water was observed at 119 degree F. Fire extinguisher was serviced on 03/15/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors.

There is a storage room at the backyard. No obstruction blocks the walkway. The last time the facility conducted the emergency drill is on 8/26/2024.

No citation were issued during today's inspection. Exit interview conducted with PM and LRM. This report was provided to LRM to review and to sign. A copy of this report was provided to LRM..
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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