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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107201724
Report Date: 02/10/2021
Date Signed: 02/11/2021 12:48:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210115171409
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:
02/10/2021
UNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Jill Stowell, Designated Representative TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility illegally evicted resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LPA Lady Cabrera conducted the subsequent complaint visit via telephone, due to Covid-19 pre-cautionary measures.

Based on the LPAs interviews and records review, the Licensee did not meet the Eviction Procedures requirements in California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87224(d), served to the Resident on 12/20/2020 and on 01/20/2021. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited on the attached LIC 9099D. Appeal Rights provided.
Substantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20210115171409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2021
Section Cited
CCR
87224(d)
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87224 Eviction Procedures (d)The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.

This requirement is not met as evidenced by:
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Administrator shall review Title 22, Division 6, Chapter 8, Section 87224: Evictions Procedures. Administrator shall provide in writing that the regulation has been read and understood by 2/20/2021.
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Based on observation, record review and interview, the Licensee did not serve the resident with a proper 30-day eviction notice, which poses an Potential Health, Safety and 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 PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2