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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002997
Report Date: 06/12/2023
Date Signed: 06/12/2023 01:23:35 PM

Document Has Been Signed on 06/12/2023 01:23 PM - 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:HOPE ALZHEIMER'S AND DEMENTIA CAREFACILITY NUMBER:
045002997
ADMINISTRATOR:BERNHARDT, JESSICA DAWNFACILITY TYPE:
775
ADDRESS:1272 ARCH WAYTELEPHONE:
(530) 592-9083
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 6CENSUS: DATE:
06/12/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 PM
MET WITH:Jessica Dawn BernhardtTIME COMPLETED:
11:25 PM
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Facility Type: ADP
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
COMP II Participants: Jessica Dawn Bernhardt, manager/admin
Interview Method: Telephone interview

On June 12, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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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