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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018893
Report Date: 05/21/2019
Date Signed: 05/21/2019 05:17:23 PM

COMPREHENSIVE INSPECTION
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:PATRICK FAMILY CHILD CAREFACILITY NUMBER:
198018893
ADMINISTRATOR:MARIA ROSA PATRICKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 470-5436
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:14CENSUS: 5DATE:
05/21/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maria Rosa Patrick, LicenseeTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rita Ramos conducted an unannounced 3 year required inspection to the above facility. LPA met with Maria Rosa Patrick, Licensee, who guided analyst on a tour of the facility. Licensee's husband James Patrick arrived during the inspection. Per Licensee, there are 5 children that are currently enrolled. A current children’s roster was not available for review. This poses a potential health and safety risk to children in care. There were 5 children present upon arrival.

This is a two-story home which consists of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, front yard and backyard (fenced). The children use the downstairs bathroom next to the stairs. Per Licensee, areas off limits to children and parents include: 3 bedrooms upstairs, 1 restroom upstairs, and the kitchen. LPA observed that there was nothing to barricade the kitchen and prevent children from accessing the kitchen during the inspection. Upon inspecting the cabinet under the sink, LPA observed that there were cleaning products. The cabinet under the sink has latches, however, one is not latching. This poses a potential health and safety risk to children in care. The licensee provides snacks, however, parents bring children their meals.

Upon inspecting the restroom that children use, LPA observed that there is a shaving razor and shampoos on the far edges of the tub. LPA advised Licensee to remove the items and to store elsewhere in which they are not accessible to children in care.

The licensee states that 2 adults and 4 children currently live in the home. Per Licensee, she currently does not have an assistant. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed child care home. Licensee disclosed that there is a firearm stored in the home. Licensee's husband guided LPA showed LPA where the firearm is stored. LPA observed that the firearm was stored together with the ammunition. This poses an immediate health and safety risk to children in care. An immediate $500 civil penalty is being assessed during today's inspection.
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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2019
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by LPA not observing a roster and Licensee's own disclosure that they do not have one. This poses a potential health and safety risk to children in care.
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Per Licensee, a copy of the roster will be submitted by POC due date of 06/04/19.
Type B
06/04/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home
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.
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Per Licensee, the latch will be fixed and personal items will be removed. Pictures will be submitted by POC due date of 06/04/19.
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This requirement is not met as evidenced by LPA observing a razor and shampoos in the bathroom that children use and cleaning products under the kitchen sink that has a broken latch. This poses a potential health and safety risk to children in care.
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Type B
06/04/2019
Section Cited
CCR
102417(g)
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Operation of a Family Child Care Home
The home shall be free from defects or conditions which might endanger a child.
This requirement is not met as evidenced by LPA observing that there are uncovered electrical outlets in the hallway. This poses a potential health and safety risk to children in care.
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Per Licensee, the outlets will be covered and pictures will be submitted by POC due date of 06/04/19.
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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2019
Section Cited
CCR
102417(g)(1)
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Operation of a Family Child Care Home

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 Marshal.
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Per Licensee, the fire extinguisher will be serviced and new batteries will be placed on the carbon monoxide detector and the gas company will check the detector. New service tag and gas company visit information will be submitted by POC due date of 06/04/19.
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This requirment is not met as evidenced by LPA observing that the carbon monoxide detector was not operating and the fire extinghuisher is expired. This poses a potential health and safety risk to children in care.
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Type B
06/04/2019
Section Cited
CCR
102417(g)(3)
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Operation of a Family Child Care Home
Where children less than five years old are in care, stairs shall be fenced or barricaded. This requirement is not met as evidenced by LPA observing that the gate that barricades the stairs is broken. This poses a potential health and safety risk to children in care.
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Per Licensee, a new gate will be purchased and a copy of the receipt will be submitted by POC due date of 06/04/19.
Type B
06/04/2019
Section Cited
CCR
102417(g)(9)(A)
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Operation of a Family Child Care Home
Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by LPA observing that there is not drill log and Licensee's own declaration that a drill has not been conducted.
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Per Licensee, a drill will be conducted and a log will be created. A copy of the log will be submitted by POC due date of 06/04/19.

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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
VISIT DATE: 05/21/2019
NARRATIVE
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All areas identified that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a landline that is used and there is also a cellphone that the Licensee utilizes. There is ventilation and heating (central). The following was observed and reviewed during this inspection.

The Licensee states that there are no poisons stored at the facility and understands that storage areas for poisons must be locked with a key or combination lock.

The valve on the required 2A 10BC fire extinguisher indicates fully charged, however, it has not been serviced. The last service indicated on the service tag is 03/15/17. Smoke detectors were tested and are operable, however, when inspecting the carbon monoxide detector, LPA observed that it was not working. LPA advised the Licensee to replace the batteries.

The home was observed to be orderly. LPA observed that the children present were all under the age of 4 and the Licensee's gate that barricades the stairs is broken. LPA advised the Licensee to replace or fix the gate. There are toys available for children. Appropriate sleeping arrangements and mats were observed.

Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. The licensee states that supervision is always provided.

The licensee is observed to be operating within the license capacity limitations.

The licensee did not have proof of Pediatric First Aid and CPR during the inspection. Per Licensee, they have not taken a class since they got licensed. There are first aid supplies available.

Children’s records were reviewed, including emergency information and were observed to be complete.


The licensee does not have proof of immunization against influenza, pertussis, and measles. The Licensee does not have the Mandated Reporter AB 1207 compliant Child Care Training Certificate.
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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
VISIT DATE: 05/21/2019
NARRATIVE
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LPA issued a Confidential Names List (LIC 811) to the licensee which documents staff and children’s files reviewed during this inspection.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Licensee stated that there has not been a drill conducted.

There is a dog on the premises. LPA observed that the dog is outside on the side of the house and the children do not have contact with the dog during operating hours.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to on a table. LPA advised Licensee to have them posted. Licensee disclosed that they were closed for a year to care for their children. LPA informed the Licensee that a report should have been made to the Department. LPA went over reporting requirements.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

Licensee is currently caring for infants. LPA advised the licensee to sleep infants where they can always be directly supervised and advised the licensee against sleeping infants in a separate room. Licensee states that infants sleep in the bedroom or living room.

LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. LPA also consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, and Safe Sleeping

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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 7 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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2019
Section Cited
HSC
1596.8662(b)(1)
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Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion
On or before March 30, 2018, a person who, on January 1, 2018, is a licensed
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Per Licensee, training will be taken and a copy of the certificate will be submitted by POC due date of 06/04/19.


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child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by LPA observing that the Licensee does not have proof of the Mandated Reporter trainign certificate. This poses a potential health and safety risk to children in care.
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Type B
06/04/2019
Section Cited
CCR
102416.1
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Reporting Requirements

The licensee shall report to the Department as provided by Health and Safety Code Sections 1597.467(b)(1) and (2).

This requirement is not met as evidenced by
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Per Licensee, reporting requirements video will be watches and a summary of what was learned will be submitted by POC dua date of 06/04/19.
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Licensee's disclosure that they were closed for a year and did not report to the Department. This poses a potential health and safety risk to children in care.
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 6 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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
VISIT DATE: 05/21/2019
NARRATIVE
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The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. Incidental Medical Services (IMS) policy was discussed. 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.

LPA advised the licensee to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.

Capacity Handout (Small & Large) was provided during this inspection.

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Upon receipt of a report documenting a Type A deficiency or substantiated complaint, the licensee shall do the following:

1. Health and Safety Code Section 1596.8595 (c) - A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b. Failure to comply with paragraph (1) shall result in an immediate civil penalty of one hundred dollars ($100).

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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 8 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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2019
Section Cited
CCR
102416(c)
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Personnel Requirements
The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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Per Licensee, a copy of the pediatric 1st Aid and CPR card will be submitted after taking the course and will be submitted by POC due date of 06/04/19.
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This requirement is not met as evidenced by LPA not observing a Pediatric 1st Aid and CPR card and Licensee's disclosure that they have not taken a class since they have been licensed. This poses an immediate health and safery risk to children in care.
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Type B
06/04/2019
Section Cited
HSC
1596.7995(c)
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Employees or volunteers at day care center; immunization requirements; records; exemptions
The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the
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Per Licensee, a copy of the immunization records will be submitted by POC dua date of 06/04/19.

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day care center.

This requirement is not met as evidenced by LPA observing that the Licensee does not have proof of immunizations.
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 5 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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2019
Section Cited
CCR
102417(g)(4)(c)
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Operation of a Family Child Care Home
Ammunition shall be stored and locked separately from firearms.
This requirement is not met as evidenced by LPA observing that the firearm stored in the home was loaded. This poses an immediate health and safety risk to children in care.
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Corrected during the inspection.
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 10 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: PATRICK FAMILY CHILD CARE
FACILITY NUMBER: 198018893
VISIT DATE: 05/21/2019
NARRATIVE
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2. Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility inspection or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. Failure to comply with paragraph (1) shall result in an immediate civil penalty of one hundred dollars ($100).

3. Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.

4. The licensee shall require each recipient of the licensing report described to sign a statement (LIC 9224) indicating that he or she has received the document and the date it was received. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this inspection.

Exit interview was conducted with Maria Rosa Patrick, Licensee, including, but not limited to Appeal Procedures, Site Visit and Initial Appeal Rights.

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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Rita RamosTELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
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