198013306-6-20-2022-33-CC-MGAA-CFKTCR-20220620143709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198013306
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:37:36 PM

Document Has Been Signed on 06/20/2022 02:37 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	ALONZO FAMILY CHILD CARE		FACILITY NUMBER:	198013306
ADMINISTRATOR:	ALONZO, SUSANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 720-1364
CITY:	MONTEBELLO	STATE: CA	ZIP CODE:	90640
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 10	CENSUS: 4	DATE:	06/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Susana Alonzo, Licensee		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	***********This inspection was conducted in Spanish********* Licensing Program Analyst (LPA) Mireya García conducted an unannounced annual required inspection. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with licensee, Susana Alonzo who guided analyst on a tour of the facility. The licensee's assistant (husband) was also present during this inspection. There were four (4) children present during LPA’s arrival with one (1) being an infant. Licensee states that there are currently 10 children enrolled. Family members residing in the home are 2 adults (criminal record clearances on file) and one minor child (licensee’s grandchild). This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, garage, front, side and back yard (fenced). The children use the restroom near the bedroom #3, living room, dining room, kitchen, garage, front, side and back yard. Per licensee, areas off limits to children and parents include: 3 bedrooms and 1 bathroom (located near living room). The LPA toured all areas used by children during this visit. Report continues on next page 1 of 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

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 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
	VISIT DATE: 06/20/2022

NARRATIVE

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During this tour, the following was noted: At 8:56 a.m., LPA was toured through the interior of the home. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating for safety and comfort. There were safe toys, play equipment and materials observed for children. At 8:58 am, LPA observed two bottles of Stella Rose Wine stored in the dining room cabinet accessible. At 9:04 am, LPA observed Shampoo accessible in the children’s restroom (picture was taken). At 9:09 am, LPA observe poisons (Raid), cleaning compounds, charcoal lighter fluid accessible in the kitchen cabinet (Pictures were taken). At 9:20 am. LPA observed poisons (Raid Ant & Roach, ORTHO-Bed Bug Killer, Snail, Slug & Insect Killer, Pictures were taken) accessible in the garage cabinet. The licensee does understand that poison must be locked with a key or combination lock. There is a working telephone service maintained in the home.

LPA observed and inspected sleeping equipment for infants. LPA observed one play yard for each infant who is unable to climb out of the play yard. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that play yard is free from loose articles and objects. There is no objects hanging above or attached to the side of the play yard. LPA observed that play yards do not hinder the entrance or exit to and from the space they are sleeping in. Bottom mat was observed to be firm and covered with a fitted sheet that is appropriate to the mat size. Each infant has their individual bedding and is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants.
Report continues on next page 2 of 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
	VISIT DATE: 06/20/2022

NARRATIVE

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Pacifiers were not observed. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping. LIC 9227 (Individual Sleeping Plan) for infants up to 12 months form was review. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the Licensee, including but not limited to documentation that shall be maintained. PIN 20-24-CCP Recently approved Safe Sleep Regulations in Effect was discuss, reviewed and a copy in Spanish was provided to the Licensee during this inspection.

Per licensee, there are no weapons, firearms or bodies of water on the premises. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged with a service tag dated 06/04/2021. Smoke detector and carbon monoxide detector in the bedroom #3 were tested at 10:12 am and are in operable condition. The licensee has current Pediatric First Aid and CPR, which will expire 03/2024.

Incidental Medical Services (IMS) policy was discussed. Per Licensee there are currently no children enrolled who required IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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.htm Report continues on next page 3 of 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 3 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
	VISIT DATE: 06/20/2022

NARRATIVE

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SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensee.
AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

The following was discussed:

· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· The Licensee shall be present in the home and shall ensure that children are supervised at all times.
· Children shall not be left in park vehicles.
· The capacity specified on the license shall be the maximum number of children for whom care can be provided.
· Car seats shall only be used for transportation purposes and shall not be used for sleeping.
· All children in care have the right to receive safe, healthful, and comfortable accommodations, furnishings and equipment.
· When a child shows signs off illness, they will be separated from other children until the nature if the illness is determined. Report continues on next page 4 of 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 4 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
	VISIT DATE: 06/20/2022

NARRATIVE

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LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home.
CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/death reporting, and criminal record transfer requirements were discussed.

LPA advised the licensee how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The following deficiencies are being cited in accordance to Title 22 of the California Code of Regulations and Health & Safety codes. Please refer to LIC809D for documentation of deficiencies cited.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent. Licensee, Susana Alonzo was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form (English/Spanish).

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative, Susana Alonzo. Report ends here page 5 of 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 06/20/2022 02:37 PM - It Cannot Be Edited

Created By: Mireya Garcia On 06/20/2022 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(4)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observing poisons (Raid, Hot Shot Foggers, Insect killer products, bed bug killer) stored in accessible unlocked cabinets. This poses an immediate health and safety risk to children in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	During LPA's inspection Licensee's husband went to purchase a lock and all poisons were removed and placed in shed with a pad lock.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Mireya Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 06/20/2022 02:37 PM - It Cannot Be Edited

Created By: Mireya Garcia On 06/20/2022 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA Garcia observing that the fire extinguisher has a Fire Marshall tag with service date of 06/04/21. This poses a potential health and safety risk to children in care.
	POC Due Date: 06/30/2022
	Plan of Correction
1 2 3 4	Per Licensee fire extinguisher will be serviced and picture of the service receipt/fire marshal tag will be submitted by POC due date of 06/30/22.

Type B

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observing cleaning compounds (Awesome, bleach, mold & mildew remover, oven & grill cleaner), two bottle of wine stored in accessible cabinets and Shampoo stored in children's restroom. This poses a potential health and safety risk to children in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	During LPA's inspection Licensee's husband placed safety latches in all cabinets were cleaning compounds are stored, wine bottles were removed and stored in the storage shed, Shampoo was placed in an area inaccessible to children.

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Mireya Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 7 of 10

Document Has Been Signed on 06/20/2022 02:37 PM - It Cannot Be Edited

Created By: Mireya Garcia On 06/20/2022 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review of Licensee's file is missing record for immunization of measles. This poses a potential health and safety risk to children in care.
	POC Due Date: 07/20/2022
	Plan of Correction
1 2 3 4	Per Licensee, she will contact her physician to request immunity record for measles and will submit proof via email to LPA Garcia on or before POC due date 07/20/22.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review of Child #6 file is missing emergency information card. This poses a potential health and safety risk to children in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Per Licensee, she will have parent complete LIC forms, and will submit LIC700 form via email to LPA Garcia on or before POC due date 06/24/22

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Mireya Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 8 of 10

Document Has Been Signed on 06/20/2022 02:37 PM - It Cannot Be Edited

Created By: Mireya Garcia On 06/20/2022 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review of Child #1, #2, #3, & #6 file is missing signed bottom portion of LIC 995A. This poses a potential health and safety risk to children in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Per Licensee, she will have parents/authorized representatives of Child #1, #2, #3 and #6 complete LIC forms, place forms on children's file, and will submit LIC995A form via email to LPA Garcia on or before POC due date 06/24/22

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Mireya Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 06/20/2022 02:37 PM - It Cannot Be Edited

Created By: Mireya Garcia On 06/20/2022 at 12:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ALONZO FAMILY CHILD CARE	FACILITY NUMBER: 198013306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of Child #1, file is missing LIC 9227. This poses a potential health and safety risk to children in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Per Licensee she will meet with child #1's parent to complete LIC9227 and will place document on file and will submit to LPA Garcia via email on or by POC due date of 06/24/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Mireya Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

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