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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006290
Report Date: 03/16/2023
Date Signed: 03/16/2023 11:50:55 AM

Document Has Been Signed on 03/16/2023 11:50 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MIMI'S SENIOR HOMEFACILITY NUMBER:
306006290
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24362 APHENA AVETELEPHONE:
(919) 317-0885
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: DATE:
03/16/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Minerva Sansano & Evelyn GacadTIME COMPLETED:
11:40 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
Method: Telephone call with CAB
COMP II Participants: Minerva Sansano & Evelyn Gacad

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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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