107201724-11-16-2023-24-AS-MFLS-CXMSYM-20231116131745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201724
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:18:05 PM

Document Has Been Signed on 11/16/2023 01:18 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	MUM'S HOME SWEET HOME, INC.		FACILITY NUMBER:	107201724
ADMINISTRATOR:	STOWELL, JILL		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:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jill Stowell		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA explained the purpose of the visit and was granted entry by caregiver staff. This annual visit was completed with Administrator, Jill Stowell.

The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 118 degrees F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked in the kitchen area. Cleaning supplies are locked and stored in the garage. Smoke detectors and carbon monoxide were checked and operating. Fire extinguishers was purchased on 11/16/2023. Last drill completed on 10/01/2023. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

Deficiencies are being cited based on LPA observation, interviews and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

During the visit a file review was conducted for residents and staff files. An exit interview was conducted, and a copy of this report was provided to Administrator, Jill S. whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 11/23/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage, infection control plan.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, record review, the licensee did not comply with the section cited above in 6 out of 6 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Licensee agrees to train staff on medication management and administrator. A copy of the training log will be submitted to the Departent by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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