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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201316
Report Date: 05/08/2024
Date Signed: 05/08/2024 11:17:55 AM

Document Has Been Signed on 05/08/2024 11:17 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MIMI'S HOUSEFACILITY NUMBER:
079201316
ADMINISTRATOR/
DIRECTOR:		MOSLEY, RASHIDFACILITY TYPE:
735
ADDRESS:2037 LA ORINDA PLTELEPHONE:
(925) 826-5127
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 0DATE:
05/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Angeline Girgis (applicant-administrator)TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger and Ardalan Gharachorloo, conducted an announced pre-licensing inspection. License application is for (6) total capacity, of which 0 maybe non-ambulatory. Fire clearance was granted on January 23,2024. LPAs met with Angeline Girgis (applicant-administrator).

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPAs inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use.Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 112.9 degrees Fahrenheit.

LPAs observed the following:
  • Facility did not have sample menu
  • Facility did not have cash resource binder

Continued on 809C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MIMI'S HOUSE
FACILITY NUMBER: 079201316
VISIT DATE: 05/08/2024
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...Continued from LIC 809
  • Facilities yard has weeds, and paint is patchy/needs updating
  • Facility did not have nonslip rugs, or shower mats
  • Facility still has cleaning solutions on counter
  • Facility did not have medication storage set up
  • Facility did not have a cover for fireplace
  • Facility did not have rail for ramp in garage
  • Facility did not have bedframe in one room
  • Facility did not have bedspread/comforters
  • Facility did not have devise for internet
  • Facility did not have PUB 475, theft and loss


Upon receipt of proof of corrections for the items above, LPA Clancy-Czuleger will come to the facility again to verify. Once LPA has verified the corrections, LPA will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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