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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850429
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:07:48 PM

Document Has Been Signed on 07/03/2024 02:07 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOMENTUM AGENCIES CREATIVE ARTS CENTER NORTHFACILITY NUMBER:
565850429
ADMINISTRATOR/
DIRECTOR:		ANDERSON, LORIFACILITY TYPE:
775
ADDRESS:2400 WILLOW LANETELEPHONE:
(818) 782-2211
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91361
CAPACITY: 100CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Jason Gillis, Lisa Degagne, Julie Ippoliti, Saier Sadiq, Eric Campbell, Leilani Whitfield, Edmond OsepansTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an announced pre-licensing visit to the facility. LPA met with Facility Administrator Jason Gillis and Licensee Representatives: Lisa Degagne, Julie Ippoliti, Saier Sadiq, Eric Campbell, Leilani Whitfield, and Edmond Osepans.

An Application to operate an Adult Day Program (ADP) was received by Community Care Licensing (CCL) on 10/23/2023. The proposed facility is a 2 (two) story standalone building located in a commercial area in Thousand Oaks, CA. A Fire Clearance was approved for a maximum capacity of 100 (one hundred) non-ambulatory clients (approved for first floor only) on 03/20/2024, during which all combination carbon monoxide/smoke detectors as well as sprinkler system and fire wall were inspected. Approximate proposed facility hours are Monday through Friday 9:00AM to 4:00PM. The program is designed with 2 (two) main components: creative and visual arts as well as a community integration training program. The facility plans to have a fully integrated program and allow accessibility to clients of varying needs and skill levels. The program is structured towards each person’s Individualized Support Plan (ISP). The facility plans to have dedicated nursing staff on site, to allow for clients of varying health needs accessibility to programs offered. Beginning at 10:34AM, a tour of the physical plant was conducted and the following observed:

The facility consists of various art studios, dance and performing arts spaces (7 in total), a kitchen, 5 (five) fully accessible restrooms, a swimming pool, changing areas including additional restrooms, exercise room, health clinic, media center, gathering space, 2 (two) basketball courts and a space that will be utilized as a cafe in the future. All rooms identified contain locked inaccessible storage space. The proposed facility does not contain an outdoor activity space. During today's visit, the pool area was observed to in need of repair/modifications, and therefore was locked and inaccessible to future clients. All other areas observed appeared to be safe and free of hazards. The bathrooms are safe and sanitary and in operating condition with toilet paper, soap, and paper towels. Hot water was measured in common sinks and measured within the required range. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOMENTUM AGENCIES CREATIVE ARTS CENTER NORTH
FACILITY NUMBER: 565850429
VISIT DATE: 07/03/2024
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The facility will comply with the organization’s standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and Needs and Services plan will be maintained for each participant and/or their authorized representative. Client records will be maintained on the facility premises in a secured area. Medications will be locked in the health clinic in a locked medication cart and the facility does have a compliant locked sharps container. First aid supplies were observed to be complete.

The program administrator meets the qualifications as specified in Title 22 regulations. Additionally, the program administrator receives and documents continuing education each year. Personnel records will be maintained at the facility in a locked staff office.

COMPONENT II/COMPONENT III ORIENTATION: A Component II Orientation was completed telephonically with the Licensee Representative on 06/04/2024. A Component III Orientation was conducted with Licensee Representatives and Administrator during today's visit.

The following needs to be completed/further discussed prior to licensure:

  • Emergency food, water and supplies need to be present at the day program location
  • Appliances including washer, dryer, refrigerator, dishwasher, microwave as well as additional furnishings in program space need to be present at the day program location
  • Plans/approximate timeline for beginning construction of the pool area submitted to CCL
  • Future plans for community integration need to be discussed and clarified, including the cafe area

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. A copy of the Licensing Report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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
LIC809 (FAS) - (06/04)
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