<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700606
Report Date: 03/11/2024
Date Signed: 03/12/2024 04:33:00 PM

Document Has Been Signed on 03/12/2024 04:33 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:MOHAMMAD ESMAEL DARMANFACILITY TYPE:
772
ADDRESS:436 NORTH WHITE ROADTELEPHONE:
(408) 259-0760
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 16CENSUS: DATE:
03/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mohammad Esmael DarmanTIME COMPLETED:
01:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/11/2024, LPA Steve Chang conducted a case management - Other to deliver an amended annual inspection report and met with Mohammad Esmael Darman, Administrator (ADM). LPA informed ADM the purpose of this Case Management Visit is to amend the Annual Required Inspection conducted by LPA Steve Chang on 02/13/2024.

No deficiency cited during today's inspection visit.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1