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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107203181
Report Date: 08/18/2021
Date Signed: 08/18/2021 10:08:33 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
COMPLAINT CONTROL NUMBER: 24-AS-20210715114239
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
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Jill Stowell, Designated RepresentativeTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Residents were left alone in the facility 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 allegation.

During the course of this complaint investigation LPA interviewed facility staff, obtained and reviewed facility records.It was confirmed that residents were left inside the facility without staff supervision during staff breaks.

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

Administrator was provided with LIC9099, LIC9099-D and Appeal Rights. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (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-20210715114239
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 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 B
08/20/2021
Section Cited
CCR
87411(a)
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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:
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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.
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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.
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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: 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)
Page: 2 of 2