107201724-8-18-2021-24-AS-SPIY-C68SA9-20210825134155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107201724
Report Date: 08/18/2021
Date Signed: 08/18/2021 09:54:11 AM

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
07/15/2021 and conducted by Evaluator Lady Cabrera

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210715113913

FACILITY NAME:	MUM'S HOME SWEET HOME, INC.		FACILITY NUMBER:	107201724
ADMINISTRATOR:	MUMFORD, DARYL		FACILITY TYPE:	740
ADDRESS:	6723 N. SIERRA VISTA AVENUE		TELEPHONE:	(559) 299-7520
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jill Stowell, Designated Representative		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff are not properly trained to use hoyer lift
Staff are not meeting residents needs
Residents were left alone in the home without staff supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations.

During the course of this complaint investigation LPA interviewed facility staff, obtained and reviewed facility records relevant to the complaint investigation. It was determined based on the interviews and records that one staff out of three staff was not trained to use the hoyer lift. It was confirmed that residents were left inside the facility without staff supervision during staff breaks. Per records and interviews, staff are not meeting resident’s needs.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D.

Administrator was provided with the LIC9099, LIC9099-D and Appeal Rights Exit interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
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.

LIC9099 (FAS) - (06/04)

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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
07/15/2021 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20210715113913

FACILITY NAME:	MUM'S HOME SWEET HOME, INC.		FACILITY NUMBER:	107201724
ADMINISTRATOR:	MUMFORD, DARYL		FACILITY TYPE:	740
ADDRESS:	6723 N. SIERRA VISTA AVENUE		TELEPHONE:	(559) 299-7520
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS:	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:			TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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9

Staff do not treat resident with respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility.
During the course of this investigation LPA interview staff and reviewed facility records relevant to the complaint investigation. It was determined that the above allegation is UNFOUNDED. Based on R1’s interview, Staff have not spoken to R1 in a degrading manner. This agency has investigated the complaint alleging (Staff do not treat resident with respect). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Administrator was provided with the LIC9099. Exit interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
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.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210715113913

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: 08/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/19/2021 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall develop a plan of correction (POC): procedure and/or policy to ensure that all staff monitor the activities of the residents while they are under the supervision of facility to ensure adequate care and supervision as defined in Section 1569.2. by POC date 08/19/2021.
	8 9 10 11 12 13 14	Based on records review and interviews, Licensee see did not provide care and/or supervision to resident, which poses an Immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 08/20/2021 Section Cited CCR 87606(f)(3)	1 2 3 4 5 6 7	87606 Care of Bedridden Residents (f) To accept or retain a bedridden... (3)Staff records... training...This requirement is not met as evidenced by: Based on records review, interview and observations, the Licensee did not ensure to have staff properly trained to use hoyer lift, which poses a potential health, safety or personal rights risk to persons in care.	1 2 3 4 5 6 7	Per Licensee, on 7/21/2021 all staff were trained on how to use the hoyer lift. Licensee will provide staff roster and the training material by 08/20/2021.
Type B 08/20/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met as evidenced by: Based on interviews and records, the Licensee did not ensure to have sufficient staff, which poses a Potential health, safety or personal rights risk to persons in care.	1 2 3 4 5 6 7	Licensee shall develop a plan of correction (POC): procedure and/or policy to ensure to have sufficent staff to meet residents need by 08/20/2021.

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	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
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

LIC9099 (FAS) - (06/04)

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