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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107203181
Report Date:
12/29/2023
Date Signed:
03/26/2024 10:35:19 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
03/26/2024 10:35 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
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
ADMINISTRATOR:
STOWELL, JILL
FACILITY TYPE:
740
ADDRESS:
6711 N. SIERRA VISTA AVENUE
TELEPHONE:
(559) 299-7520
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93710
CAPACITY:
6
CENSUS:
6
DATE:
12/29/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:59 AM
MET WITH:
Jill Stowell
TIME COMPLETED:
11:45 AM
NARRATIVE
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Report.pdf
SUPERVISOR'S NAME:
Brenda White
TELEPHONE:
(559) 243-8080
LICENSING EVALUATOR NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
12/29/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
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Document Has Been Signed on
03/26/2024 10:35 AM
- 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
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:
12/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
87555(b)(27)
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POC attached
01/10/2024
Section Cited
CCR
87608(a)(5)(A)
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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:
Brenda White
TELEPHONE:
(559) 243-8080
LICENSING EVALUATOR NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
12/29/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/29/2023
LIC809
(FAS) - (06/04)
Page:
2
of
2