107201724-11-20-2024-24-AS-DBOD-DB7SXT-20241120131629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201724
Report Date: 11/20/2024
Date Signed: 11/20/2024 01:20:14 PM

Document Has Been Signed on 11/20/2024 01:20 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/ DIRECTOR:	STOWELL, JILL		FACILITY TYPE:	740
ADDRESS:	6723 N. SIERRA VISTA AVENUE		TELEPHONE:	(559) 299-7520
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Jill Stowell		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Daiquiri Boyd 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 laundry room closet. Smoke detectors and carbon monoxide were checked and operating. Fire extinguishers was purchased on 11/19/2024. Last drill completed on 09/06/2024. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction. LPA observed a 6ft. fence around an emptied swimming pool in the backyard. The gate to the pool area is locked. There are two bedrooms that have doors that open to the pool portion of the backyard, one of those residents is bedridden and the other is ambulatory. LPA and Administrator discussed adding additional fencing to prevent residents accessing the pool area from the resident's rooms.

Deficiency is being cited based on LPA observation 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 caregiver, Gloria Gil, whose signature confirms receipt.

(continued on next page)

Sergiy Pidgirny	TELEPHONE: (559) 243-8080
Daiquiri Boyd	TELEPHONE: 559-243-8080
	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

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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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
	VISIT DATE: 11/20/2024

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LPA discussed the updating and maintenance of the home with the Administrator. LPA and Administrator discussed that the home is an older home and has 6 residents plus staff, and this is a lot of wear and tear on a home. LPA and Administrator discussed updating kitchen and bathroom fixtures and cabinets. All flooring in the home is newer tile and is in good condition.

LPA requested the following updated forms faxed to CCLD by 11/29/24: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri Boyd	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 01:20 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: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Accommodations and Services

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the backyard area fencing is not covering bedroom exits and keeping residents out of the empty swimming pool area which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Administrator stated that they will install a new fence with a gate in the backyard on the side of the home, which currently allows two residents to exit from their rooms and into the backyard pool area. This fence/gate will be installed by December 20, 2024 and Administrator will send pictures of repairs to Licensing by that 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.

Sergiy Pidgirny	TELEPHONE: (559) -243-8080
Daiquiri Boyd	TELEPHONE: 559-243-8080
	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC809 (FAS) - (06/04)

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