<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201316
Report Date:
05/29/2024
Date Signed:
05/29/2024 10:35:37 AM
Document Has Been Signed on
05/29/2024 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
MIMI'S HOUSE
FACILITY NUMBER:
079201316
ADMINISTRATOR/
DIRECTOR:
MOSLEY, RASHID
FACILITY TYPE:
735
ADDRESS:
2037 LA ORINDA PL
TELEPHONE:
(925) 826-5127
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
6
CENSUS:
0
DATE:
05/29/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Angeline Girgis, applicant-administrator
TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Jill Clancy-Czuleger conducted an announced Component III Training. Component III was attended by Angeline Girgis (applicant-administrator). LPA presented the training via Power Point presentation and had a discussion with applicants.
Exit interview conducted and copy of this report provided at the conclusion of the training
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
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
1