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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203181
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:04:36 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/28/2024 10:04 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, JILLFACILITY TYPE:
740
ADDRESS:6711 N. SIERRA VISTA AVENUETELEPHONE:
(559) 299-7520
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 6DATE:
03/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Jill StowellTIME COMPLETED:
10:15 AM
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PA Shawna Doucette arrived at the facility unannounced to conduct a Required Annual Inspection. LPA was granted entry by Administrator Jill Stowell. LPA explained the purpose of the visit and met with Administrator Jill Stowell. LPA did not have the option available to select the Required 1 Year. LPA was unable to access the care tool and conducted the inspection under Case Management Annual Continuation.

A tour of the facility was conducted with the Administrator. The residence was set at 71 F temperature and free of passageway obstructions inside and outside. Facility water temperature measured at 109 F. Facility has an infection control plan and an emergency disaster plan. Facility does not currently have any residents on hospice or any with restricted health care plans.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication closet. Cleaning supplies were in a locked closet. Smoke detectors and carbon monoxide detectors were tested and working. Fire extinguisher is 11/15/23. Facility conducted a fire and earthquake drill on 10/2/23.

There was outdoor seating for the residents. Facility has a pool that has a gate which was locked an inaccessible to residents in care.

Resident files and staff files were reviewed. CPR/First Aid is current. Resident medications were reviewed.

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A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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