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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201724
Report Date: 08/18/2021
Date Signed: 08/18/2021 09:58:15 AM

Document Has Been Signed on 08/18/2021 09:58 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MUM'S HOME SWEET HOME, INC.FACILITY NUMBER:
107201724
ADMINISTRATOR:MUMFORD, DARYLFACILITY TYPE:
740
ADDRESS:6723 N. SIERRA VISTA AVENUETELEPHONE:
(559) 299-7520
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 6DATE:
08/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Jill Stowell, Designated RepresentativeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Lady Cabrera while investigating complaint on 07/19/2021. LPA met with Designated Representative Jill Stowell. It was discovered that the facility admitted a bedridden resident and did not obtain appropriate fire clearance.

Deficiencies cited on the attached 809D. Administrator was informed that as a COVID-19 precautionary measure, LIC809, LIC809-D, LIC421IM and Appeal Rights will be emailed to the Administrator. Exit interview conducted.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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 2
Document Has Been Signed on 08/18/2021 09:58 AM - It Cannot Be Edited


Created By: Lady Cabrera On 08/18/2021 at 09:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MUM'S HOME SWEET HOME, INC.
FACILITY NUMBER: 107201724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2021
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department…(2) Bedridden persons

This requirement is not met as evidenced by:
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On 07/20/2021, Licensee submitted LIC9054, LIC200, LIC500, LIC610D and a facility sketch to CCLD for fire clearance request.
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Based on observation and records review, the Licensee did not obtain appropriate fire clearance for a bedridden resident, which poses an Immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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