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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203181
Report Date: 08/18/2021
Date Signed: 08/18/2021 10:16:23 AM

Document Has Been Signed on 08/18/2021 10:16 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 2, INC.FACILITY NUMBER:
107203181
ADMINISTRATOR:MUMFORD, DARYLFACILITY TYPE:
740
ADDRESS:6711 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:
10:15 AM
MET WITH:Jill Stowell, Designated RepresentativeTIME COMPLETED:
10:40 AM
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
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 did not have the current facility license posted and was not following the fire clearance special conditions. LPA provided Licensee with the most current license and City of Fresno Fire Clearance posting.

Deficiencies cited on the attached 809D. Administrator was provided with the LIC809, LIC809-D and Appeal Rights. 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 10:16 AM - It Cannot Be Edited


Created By: Lady Cabrera On 08/18/2021 at 10:11 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 2, INC.
FACILITY NUMBER: 107203181

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)

1
2
3
4
5
6
7
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee posted current facility license. On 07/21/2021, Licensee submitted LIC9054, LIC200, LIC500, LIC610D and a facility sketch to CCLD for fire clearance request.
8
9
10
11
12
13
14
Based on observation, the Licensee did not ensure to have the current facility license posted and was not following the fire clearance special conditions, which poses an Immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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)
Page: 2 of 2