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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700606
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:54:21 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/13/2023 04:54 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:LAUREN MCCHESNEYFACILITY TYPE:
772
ADDRESS:436 NORTH WHITE ROADTELEPHONE:
(408) 259-0760
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:16CENSUS: 14DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mohammad Esmael DarmanTIME COMPLETED:
02:12 PM
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Licensing Program Analyst Steve Chang conducted an Annual Inspection and met with program manager/administrator (ADM) Mohammad Esmael Darman. Upon arrival at facility, the front office staff took LPA body temperature, and checked in LPA in the visitor log book. LPA observed COVID-19 posters in the facility. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance.

LPA toured the facility with ADM. There are 10 resident rooms including 4 single rooms and 6 shared rooms. LPA observed the beds in the shared rooms were 6 foot apart. Copy room/Break room, Administrative office, Manager office, staff offices, 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. Trash cans were observed with covers. Posters of washing hands for 20 seconds were observed by the sinks in restrooms. All paper towels were observed either with dispenser or with holders. Room temperature was observed at 71 degree F, and hot water temperature was observed at 112 degree F. PPE supplies were observed sufficient. Medication supplies were observed locked in the Med room. Knives were observed locked in kitchen. Detergent supplies were observed locked in the storage room.

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 already submitted the 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.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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