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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360907998
Report Date: 10/12/2021
Date Signed: 10/12/2021 09:27:47 AM

Document Has Been Signed on 10/12/2021 09:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEW HOPEFACILITY NUMBER:
360907998
ADMINISTRATOR:VILLA, ABIGAILFACILITY TYPE:
735
ADDRESS:1348 1/2 WEST CONGRESSTELEPHONE:
(909) 381-2018
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92410
CAPACITY: 6CENSUS: 4DATE:
10/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lisa Mendez, AdministratorTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted this unannounced case management visit for the purpose of conducting a health and safety welfare visit. During this visit LPA, assessed the food supply, toured resident living areas, met four residents and reviewed and obtained copies of one resident record (R1).
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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