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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494827
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:48:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ACHIEVERS ACADEMY PRESCHOOLFACILITY NUMBER:
197494827
ADMINISTRATOR:MARIA GOLDMANFACILITY TYPE:
850
ADDRESS:9025 LANGDON AVENUETELEPHONE:
(818) 830-8123
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:150CENSUS: 32DATE:
08/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Mitul Sharma, Applicant and Maria Goldman, DirectorTIME COMPLETED:
05:00 PM
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On 08/20/2021 at 8:35 a.m. Licensing Program Analysts (LPA) Deborah Lowe and Judy Laureano met with Applicant Mitul Sharma and Director Maria Goldman. The purpose of the visit was an announce pre-licensing inspection at the facility to ensure that health, safety and personal rights as requires by Title 22 and Health and Safety Regulations governing California Child Care Centers will be met. There were 32 children were present during this inspection. This is an application for change of ownership with 150 children, ages 2 years to entry into 1st Grade. The child care center will operate Monday – Friday 6:30 a.m. – 6:00 p.m. The fire clearance was approved on 05/25/2021.

LPAs Lowe and Laureano toured and measured the on-limits areas and classrooms located at the facility. The facility has a total of 8 classrooms. Fire Extinguishers show a service date of 3/15/2021. Children will have access to 13 sinks and 13 toilets.

Classroom measurements are:

· Room #1 = (26.67 x 22.75) = 606.74, - (9.83 x 1.67) = 16.42, - (11.75 x 1.0) = 11.75

606.74 – 16.42 – 11.75 = 578.57

· Room #2 = (23.67 x 21.42) = 507.01, + (8.33 x 14.17) = 118.03, - (10.25 x 1) = 10.25, - (2 x 1.67) = 3.34

507.01 + 118.03 - 10.25 - 3.34 = 611.45

· Room #3 = (29.83 x 17.58) = 524.41, - (10.25 x 1) = 10.25, - (2 x 1.67) = 3.34

524.41 - 10.25 - 3.34 = 510.82

· Room #4 = (33.42 x 18.17) = 607.24, - (17.58 x 1) = 17.58, (2 x 1.67) = 3.34

607.24 – 17.58 – 3.34 = 586.32

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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· Room #5 = (29.25 x 18.17) = 531.47, - (2 x 1.67) = 3.34, - (17.5 x 1) = 17.5

531.47 – 3.34 – 17.5 = 510.63

· Room #6 = (32.42 x 29.83) = 967.09, - (5.83 x 1) = 5.83, - (11.75 x 1) = 11.75, - (2 x 1.67) = 3.34, - (2 x 1.67) = 3.34. 967.09 – 5.83 – 11.75 – 3.34 – 3.34 = 942.83

· Room #7 = (16.58 x 21.75) = 360.62, + (14.17 x 7.92) = 112.23, - (11.83 x 1) = 11, - (2 x 1.67) = 3.34

360.62 + 112.23 – 11 – 3.34 = 457.68

· Room #8 = (22.05 x 21.75) = 479.57, - (2 x 1.67) = 3.34, (4.83 x 2) = 9.66, - (11 x 1) = 11

479.57 – 3.34 – 9.66 – 11 = 455.59

Total Indoor Activity Space measures: 578.57 + 611.45 + 510.82 + 586.23 + 510.63 + 942.83 + 457.68 + 455.59 = 4,653.89 divided by 35 sq feet = 132 Children.

Outdoor Play measurements are:

Outdoor activity area is along the side the classrooms with two outdoor activity area’s in front of the facility. Outdoor activity areas are sectioned by metal gates and run the length of the building.

(27.42 x 44.42) + (7.75 x 0.83) = 1224.43 + (38.05 x 31.67) = 1205.04 + (48.50 x 36.05) = 1748.43 + (48.42 x 37) = 1791.54 + (34.25 x 31) = 1061.76 + (14.58 x 30.75) = 448.34 + (38.67 x 22.05) – (7 x 4) = 824.67 + (33.05 x 22.58) = 746.27

Total outdoor activity space: 1224.43 + 1205.04 + 1748.43 + 1791.54 + 1061.76 + 448.34 + 824.67 + 746.27 = 9,050.48 divided by 75 sq feet = 120 Children.

Indoor/Children’s Area:

LPA Lowe and LPA Laureano all direct access with outdoor and indoor passageways to be free of obstruction. Emergency exit pathway on backside of building was observed with passageway to be with hazards and observed with obstructions. LPA Lowe and LPA Laureano observed the child care center be clean, safe, sanitary and in good repair at all times to ensure the safety and

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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well-being of children, employees and visitors. Floors of all rooms were observed to have a surface that was safe and clean. A comfortable temperature for children shall be maintained at all times. Furniture and equipment was observed to be maintained in good condition, free of sharp, loose or pointed parts. Tables and chairs were observed to be provided to meet the needs of the children. All play equipment and materials used by children appeared be age-appropriate. The facility was observed to have built in individual permanent cubby space for children’s clothing, personal belongings and/or bedding. All materials and surfaces accessible to children, including toys, were observed to be free of toxic substances.

LPA Lowe and LPA Laureano advised drinking water from a non-contaminating fixture or container shall be readily available both indoors and in the outdoor activity area. The facility has a monthly pest control service to keep the center free of flies, other insects, and rodents. All containers used for storage of solid wastes, including moveable bins, observed to have a tightfitting cover; however, advised that is cover is to be kept closed.

Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. Storage areas for poisons shall be locked. LPA Lowe and LPA Laureano observed cleaners in teacher cabinets and was advised to add a latch to ensure inaccessible to children. The licensee shall maintain the following first-aid supplies in a location accessible to staff but inaccessible to children: LPA Lowe and LPA Laureano observed a current edition of a first-aid manual, sterile first-aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometer, antiseptic solution.

A center shall be equipped to isolate and care for any child who becomes ill during the day. The Director stated isolation area will be in the Director office to afford easy supervision of children by center staff. The Director stated the isolation when child is in the isolation area their cot from their classroom for each ill child. LPA Lowe and LPA Laureano advised the isolation area shall not be located in the kitchen area or the general-use toilet area.

Every licensed child day care center shall have one or more carbon monoxide detectors in the facility. LPA Lowe and LPA Laureano observed a working carbon monoxide detector along with smoke detectors. Applicant tested both units, LPA Lowe and LPA Laureano were able to hear a successful test. LPA Lowe and LPA Laureano observed the facility to have working telephone service on the premises.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following:

The licensee shall be responsible for ensuring that children with obvious symptoms of illness including, but not limited to, fever or vomiting, are not accepted. Director stated facility completes a daily health inspection for each child and staff.

LPA Lowe and LPA Laureano advised smoking is prohibited on the premises of a child care center as specified in Health and Safety Code Section 1596.795(b).

LPA Lowe and LPA Laureano advised a baby walker shall not be allowed on the premises of a child care center in accordance with Health and Safety Code Sections 1596.846(b) and (c).

There shall be at least 35 square feet of indoor activity space per child based on the total licensed capacity.

Based on the total licensed capacity, one toilet and one handwashing fixture shall be maintained for every 15 children, or fraction thereof.

Napping:

LPA Lowe and LPA Laureano cots used for napping and were observed be maintained in a safe condition. Covered with vinyl that can be wiped. Director stated cots are wiped with a detergent/disinfectant weekly or when soiled or wet.

Each cot or mat shall be equipped with a sheet to cover the cot or mat and, depending on the weather, a sheet and/or blanket to cover the child. Director stated families provide sheets and blankets and are sent home weekly.

The licensee shall provide a variety of age-appropriate equipment, toys and materials in good condition and in sufficient quantity to allow children present to fully participate in planned activities.

Restrooms:

All toilets, handwashing and bathing facilities were observed to be maintained in safe and sanitary operating condition. Additional equipment, aids and/or conveniences shall be provided as needed in centers that serve Page 4

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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children with physical disabilities.

LPA Lowe and LPA Laureano advised hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by children to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

Notwithstanding (e) and (e)(1) above, handwashing fixtures shall not be required to deliver hot water.

There shall be one toilet and one handwashing fixture, separate from and in addition to the number of toilets and handwashing fixtures required in (h) above, designated for use by children who are ill, for use by staff, and for emergency use. This toilet and handwashing fixture shall be conveniently located in relation to the isolation area. Staff toilet located in the director’s office will be used for ill children in isolation area.

Common towels or washcloths are prohibited.

Outdoor:

LPA Lowe and LPA Laureano observed the outdoor area to have a shaded rest area for the children. LPA Lowe and LPA Laureano observed the outdoor area to be free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard. As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment observed to be cushioned with material that absorbs falls.

The playground was observed be enclosed by a fence to protect children and to keep them in the outdoor activity area. The fence shall be at least four feet high. Outdoor area was in 7 gated sections.

LPA Lowe and LPA Laureano advised any construction or equipment that could pose a hazard in the outdoor activity area shall be made inaccessible to children in care. This shall include, but not be limited to, incinerators, air- conditioning equipment, water heaters, and fuse boxes.

LPA Lowe and LPA Laureano did not observe any bodies of water.

There shall be at least 75 square feet per child of outdoor activity space based on the total licensed capacity.

Health Related Services:

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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Medications shall be kept in a safe place inaccessible to children, located in the Director’s office. A refrigerator shall be used to store any medication that requires refrigeration.

Facility develop and implement a written plan to record the administration of prescription and nonprescription medications and to inform the child's authorized representative daily when such medications have been given.

Food Service:

LPA Lowe and LPA Laureano advised all food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

All foods or beverages capable of supporting the rapid and progressive growth of microorganisms that can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.

Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food-preparation areas, or areas where kitchen equipment or utensils are stored.

Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

All kitchen, food-preparation and storage areas was observed to be clean and free of litter and rubbish; and measures shall be taken to keep all such areas free of rodents and other vermin.

The food-preparation area shall not be used for: Children's play activities, unless such activities are part of a supervised food-education program. Full-day programs shall offer a midmorning and a midafternoon snack.

Facilities provide breakfast, lunch, and an afternoon snack.

Kitchen is off limits to children with access door outside of the building across from playground. LPA Lowe and LPA reminded applicant even though kitchen is off limits to children sharps and cleaners still need to be in a locked cabinet as additional precaution for children safety.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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Postings:

LPA Lowe and LPA Laureano observed the current license posted in a prominent, publicly accessible location in the center. LPA Lowe and LPA Laureano observed the following postings in addition to the license: the LIC 613A (9/96), the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster posted in a prominent location, and menu’s.

LPA Lowe and LPA Laureano advised menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

The licensee shall post signs at the entrance to the child care center that provide the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5 FORM: LIC 610 LPA Lowe and LPA Laureano observed the LIC 610 posted in each classroom.

LPA Lowe and LPA Laureano advised each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. Contingency plans for action during fires, floods and earthquakes including, but not limited to, the following: FORM: LIC 9148 was observed.

The following was discussed:

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.html.

Employee/Volunteer Files shall also be maintained and shall contain the following


Health Screening Report - Facility Personnel (LIC 503) and TB Clearance.
Proof of Immunization's
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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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TB Clearance and "Good Health" statement from volunteers.
Personnel Record (LIC 501) or application/resume.
Evaluation of Director Qualifications (LIC 9096).
Evaluation of Teacher Qualifications (LIC 9095).
For each aide under age 18, verification of high school graduation or current participation in an occupational program conducted by an accredited high school or college.
Criminal Record Statement (LIC 508) for staff subject to fingerprint requirements.
Fingerprint clearances - Proof of clearance (Criminal Record, FBI and Child Abuse).
Appropriate driver's license for person(s) transporting children.

Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training.
Website: www.mandatedreporterca.com

Senate Bill (SB) 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

Senate Bill (SB) 277 New Immunization Requirement: Beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACHIEVERS ACADEMY PRESCHOOL
FACILITY NUMBER: 197494827
VISIT DATE: 08/20/2021
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The following corrections are needed before a capacity increase will be considered:

· Clear emergency exit pathway on side of building along classrooms

· Service fire extinguisher in room 4 – showing service date of 3/18/2019

· Outlet cover in room 8 above TV is in need of repair

· Make cleaning chemicals and teachers personal belongings inaccessible to children

· Repair peeling paint on wall

· Remove toy bins that are broken in the unoccupied room

· Clean carpet in room 1

· Make sharps and cleaners inaccessible to children in the kitchen

· Update facility sketch to show off limit areas

· Provide disaster and mass casualty plan of action

  • Repair - Outdoor gate near office building gate did not close property
  • Outdoor Activity Waiver Request with classroom and outdoor plan schedule

LPAs Lowe and Laureano left facility at 11:40 am to prepare written report and returned to facility at 3:50 pm.

An exit interview was conducted with the above items discussed and a copy of this report was provided to the Applicant. Final license determination will be made upon review by the Licensing Program Manager and correction of the above issues. Applicant to correct items by 9/03/2021.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9