073407426-1-14-2022-52-CC-JJAG-CAUPD9-20220120101311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073407426
Report Date: 01/14/2022
Date Signed: 01/14/2022 02:18:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Julia Placencia

COMPLAINT CONTROL NUMBER: 52-CC-20211020083039

FACILITY NAME:	REDWOODS INTERNATIONALE MONTESSORI, THE		FACILITY NUMBER:	073407426
ADMINISTRATOR:	LILES, RACHEL		FACILITY TYPE:	850
ADDRESS:	2400 OLD CROW CANYON RD		TELEPHONE:	(925) 743-0800
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	60	CENSUS: 0	DATE:	01/14/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Annagi Liles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff using inappropriate napping methods for day care children

INVESTIGATION FINDINGS:

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On January 14, 2022 at 12:10pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced to complete the complaint investigation regarding the allegation above. LPA met with licensee Annagi Liles. There were no children or staff present due to a confirmed case of COVID.

During the course of the investigation LPA toured the facility, conducted interviews with complainant, licensee, staff, parents and children, and also reviewed documents. it has been disclosed that the licensee has at times forced children to lay still, sometimes with their arms out and/or their heads covered with a blanket, to make them take a nap. These napping methods are a violation of children’s personal rights.

Based on observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Failure to submit Proof of Corrections (POC) by Plan of Correction date may result in additional civil penalties. ***Continued on 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
	VISIT DATE: 01/14/2022

NARRATIVE

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The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in each child's file to be reviewed by licensing.

Exit interview conducted with licensee Annagi Liles and copy of report provided. A Notice of Site Visit was provided and must be posted for 30 days.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/21/2022 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating,	1 2 3 4 5 6 7	POC: Licensee and staff will watch the licensing video on Children's Personal Rights in Child Care on the CCL website. Each staff is to write a statement indicating their understanding of personal rights, and how they will ensure that the personal rights of children are protected at all times. Submit statements to LPS by due date of 1/21/22.
	8 9 10 11 12 13 14	sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning - This requirement is not met as evidenced by: Based on interviews conducted, the licensee has forced children to lay still with their arms out and/or covered their heads with a blanket to nap which is an immediate healthy and safety or personal rights risk to children.	8 9 10 11 12 13 14	Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Julia Placencia

COMPLAINT CONTROL NUMBER: 52-CC-20211020083039

FACILITY NAME:	REDWOODS INTERNATIONALE MONTESSORI, THE		FACILITY NUMBER:	073407426
ADMINISTRATOR:	LILES, RACHEL		FACILITY TYPE:	850
ADDRESS:	2400 OLD CROW CANYON RD		TELEPHONE:	(925) 743-0800
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	60	CENSUS: 0	DATE:	01/14/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Annagi Liles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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9

Staff left day care child unattended

INVESTIGATION FINDINGS:

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On January 14, 2022 at 12:10pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced to complete the complaint investigation regarding the allegation above. LPA met with licensee Annagi Liles. There were no children or staff present due to a confirmed case of COVID.

During the course of the investigation LPA toured the facility, conducted interviews with complainant, licensee, staff, parents and children, and also reviewed documents. There is not enough evidence to determine if this allegation is true or false.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with licensee Annagi Liles and copy of report provided. A Notice of Site Visit was provided and must be posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Julia Placencia

COMPLAINT CONTROL NUMBER: 52-CC-20211020083039

FACILITY NAME:	REDWOODS INTERNATIONALE MONTESSORI, THE		FACILITY NUMBER:	073407426
ADMINISTRATOR:	LILES, RACHEL		FACILITY TYPE:	850
ADDRESS:	2400 OLD CROW CANYON RD		TELEPHONE:	(925) 743-0800
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	60	CENSUS: 0	DATE:	01/14/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Annagi Liles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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8
9

Staff forces day care children to eat

INVESTIGATION FINDINGS:

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On January 14, 2022 at 12:10pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced to complete the complaint investigation regarding the allegation above. LPA met with licensee Annagi Liles. There were no children or staff present due to a confirmed case of COVID.

During the course of the investigation LPA toured the facility, conducted interviews with complainant, licensee, staff, parents and children, and also reviewed documents. There is not enough evidence to determine if this allegation is true or false.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with licensee Annagi Liles and copy of report provided. A Notice of Site Visit was provided and must be posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Julia Placencia

COMPLAINT CONTROL NUMBER: 52-CC-20211020083039

FACILITY NAME:	REDWOODS INTERNATIONALE MONTESSORI, THE		FACILITY NUMBER:	073407426
ADMINISTRATOR:	LILES, RACHEL		FACILITY TYPE:	850
ADDRESS:	2400 OLD CROW CANYON RD		TELEPHONE:	(925) 743-0800
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	60	CENSUS: 0	DATE:	01/14/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Annagi Liles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff forces day care children to potty train

INVESTIGATION FINDINGS:

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On January 14, 2022 at 12:10pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced to complete the complaint investigation regarding the allegation above. LPA met with licensee Annagi Liles. There were no children or staff present due to a confirmed case of COVID.

During the course of the investigation LPA toured the facility, conducted interviews with complainant, licensee, staff, parents and children, and also reviewed documents. it has been disclosed that the licensee has made children sit on the potty for an excessive amount of time to which they are left crying. This method of potty training is a violation of children’s personal rights.

Based on observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Failure to submit Proof of Corrections (POC) by Plan of Correction date may result in additional civil penalties. ***Continued on 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
	VISIT DATE: 01/14/2022

NARRATIVE

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/21/2022 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating,	1 2 3 4 5 6 7	POC: Licensee and staff will watch the licensing video on Children's Personal Rights in Child Care on the CCL website. Each staff is to write a statement indicating their understanding of personal rights, and how they will ensure that the personal rights of children are protected at all times. Submit statements to LPS by due date of 1/21/22.
	8 9 10 11 12 13 14	sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning - This requirement is not met as evidenced by: Based on interviews conducted, the licensee has left children crying on the potty for an excessive amount of time, which is an immediate healthy and safety or personal rights risk to children.	8 9 10 11 12 13 14	Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Julia Placencia

COMPLAINT CONTROL NUMBER: 52-CC-20211020083039

FACILITY NAME:	REDWOODS INTERNATIONALE MONTESSORI, THE		FACILITY NUMBER:	073407426
ADMINISTRATOR:	LILES, RACHEL		FACILITY TYPE:	850
ADDRESS:	2400 OLD CROW CANYON RD		TELEPHONE:	(925) 743-0800
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	60	CENSUS: 0	DATE:	01/14/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Annagi Liles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is not providing a comfortable environment for day care children

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On January 14, 2022 at 12:10pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced to complete the complaint investigation regarding the allegation above. LPA met with licensee Annagi Liles. There were no children or staff present due to a confirmed case of COVID.

During the course of the investigation LPA toured the facility, conducted interviews with complainant, licensee, staff, parents and children, and also reviewed documents. it has been disclosed that the licensee has at times violated children’s personal rights by her verbal interaction with children in care which includes a harsh tone of voice and/or choice of words.

Based on observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Failure to submit Proof of Corrections (POC) by Plan of Correction date may result in additional civil penalties. ***Continued on 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 9 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
	VISIT DATE: 01/14/2022

NARRATIVE

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SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 10 of 11

Control Number 52-CC-20211020083039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: REDWOODS INTERNATIONALE MONTESSORI, THE	FACILITY NUMBER: 073407426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/21/2022 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating,	1 2 3 4 5 6 7	POC: Licensee and staff will watch the licensing video on Children's Personal Rights in Child Care on the CCL website. Each staff is to write a statement indicating their understanding of personal rights, and how they will ensure that the personal rights of children are protected at all times. Submit statements to LPS by due date of 1/21/22.
	8 9 10 11 12 13 14	sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning - This requirement is not met as evidenced by: Based on interviews conducted, the licensee has at times verbally interacted with children inappropriately using a harsh tone of voice, which is an immediate healthy and safety or personal rights risk to children.	8 9 10 11 12 13 14	Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC9099 (FAS) - (06/04)

Page: 11 of 11