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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019893
Report Date: 10/08/2021
Date Signed: 10/11/2021 08:29:27 AM

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:LIU & YUAN FAMILY CHILD CAREFACILITY NUMBER:
198019893
ADMINISTRATOR:LI LIU & FLORA YUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 327-1102
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY:14CENSUS: 6DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Li LiuTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Alanna Gontarek and Lilli Babcock conducted an unannounced annual inspection to the above facility. LPAs met with FLORA YUAN, Licensee who guided analyst on a tour of the facility indoors and outdoors. Also present during this inspection, was Co-Licensee Li Liu. Per Licensee, there is one additional adult living in the home, Licensee's father. Per Licensee, there are 6 children that are currently enrolled. The Licensee is within the conditions, limitations, and capacity specified on the license. A current children’s roster was available for review. There were 6 children present during this inspection. Hours of operation are: Monday to Friday from 8:00 a.m. to 6:00 p.m.

All areas identified on the facility sketch were inspected. This is a one story home which consists of 5 bedrooms, 3 1/2 bathrooms, two kitchens, dining room, two living rooms, office, garage, backyard, side patio and front yard (fenced). The front part of the home does have the same address. Daycare areas include: the 1/2 restroom outside in patio, the living room in back house, one bedroom/nap room, dining room/entry way, and side patio for play. These areas were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central).

Areas off limits to children and parents include: 4 bedrooms, Nap room, 3 bathrooms, both kitchens (kiddie gate blocks entrance in back part of house), front part of house which has separate entrance, back yard and garage. The doors to these areas are locked. The applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary. The licensee provides fresh perishable and non-perishable food in the home in a quantity to meet the needs of the next 3 meals and between meal snacks.

The licensee states that a total of 3 adults and 0 children currently live in the home. 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.

There is telephone service via landline and a cellphone that is used and the cellphone stays at the facility during operation hours. There is ventilation and heating (central). Licensee states that there are no firearms, or firing pins, stored in the home.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
VISIT DATE: 10/08/2021
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The following was observed and reviewed during this inspection:
Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. Poisons are locked in the key locked and is stored in the garage. The restroom that children use was observed to be safe and sanitary.
Fireplaces and open face heaters are inaccessible to children. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was purchased on 7/15/2021. Smoke and carbon monoxide detectors were tested and are operable.

The home is observed to not be clean or orderly. At 10:53 a.m., LPAs inspected off-limit kitchen area. LPAs observed clutter, flies, open food items, and expired food items sitting out on kitchen counter and kitchen table. Pictures were taken. There are toys available for children. Children have individual mats and cribs, including comfortable mattresses, clean linens, and blankets that are in good repair. Sleeping arrangements were observed. Per Licensee, there are 6 mats and LPAs observed 2 cribs in nap room. Isolation area is located in the nap room.

Currently, children are using the side patio 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. LPAs did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided. LPAs did not observe bodies of water.

The licensee and other personnel have completed training on preventive health practices including Pediatric CPR and First Aid. Both licensee's Pediatric CPR and First Aid expires on 7/2023. There are first aid supplies available. LPAs observed first aid supplies located in dining area/entry way.

Children’s records were reviewed, including emergency information. At 12:00 p.m., during record review, LPAs observed 3 out of 6 children missing proof of the LIC 700 Identification and Emergency Information form in the children's files. Child #2, Child #4, and Child #5 are missing LIC 700 form. Child #3 has partial completion of LIC 700 form. LPAs observed 6 out of 6 children missing the Parent's Rights form (LIC 995) from the all child files reviewed. 3 infants enrolled (Child #3, Child #4, and Child #5) were missing the LIC 9227 Individual Infant Sleeping Plan on file. Per Licensee, was not aware of the new LIC 9227 form or Safe Sleep Regulations. LPAs did not observe Sleep logs for the 3 infants attending the daycare. The 3 infants missing proof of Sleep Logs are: Child #3, Child #4, and Child #5.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 2 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
VISIT DATE: 10/08/2021
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The licensees have proof of immunization against influenza, pertussis, and measles. Both Licensees are exempt from completing the Mandated Reporter AB 1207 Training due to English not being a first language. Per Licensee, both licensee's have Mandarin as a first language.

LPA issued a LIC 857 and LIC 859 Confidential Names list for files reviewed.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. During record review, LPAs did not observe fire or earthquake drill logs. Per Licensee, does not have a log. Per Licensee, does not conduct regular fire or earthquake drills.

There are pets on the premises. Per Licensee, has 6 cats and fish and they stay in the off-limit front part of the home during operating hours.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.

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.

Infants in Care: LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that cribs are not free from loose articles and objects. At 10:39 a.m., LPA observed 2 cribs for each infant who is unable to climb out of the crib located in the nap room. One crib had one blanket, one soft toy, and a crib liner (non-mesh). The other crib observed had a mesh crib liner partial detached to the crib. Licensee immediately removed all loose items from both cribs, and removed crib liners. LPA observed that cribs do not hinder the entrance or exit to and from the space they are sleeping in. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Each infant has their individual bedding and per Licensee, is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants. 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. 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.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
VISIT DATE: 10/08/2021
NARRATIVE
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During record review, at 12:30 p.m., LPAs did not observe Sleep logs for the 3 infants attending the daycare. The 3 infants missing proof of Sleep Logs are: Child #3, Child #4, and Child #5. During child record review, at 12:30 p.m., the 3 infants enrolled (Child #3, Child #4, and Child #5) were missing did not have the LIC 9227 Individual Infant Sleeping Plan on file. Per Licensee, was not aware of the new LIC 9227 form or Safe Sleep Regulations.
LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Capacity Handout (Small & Large) and LIC 9227 Individual Infant Sleeping Plan was explained and provided during this inspection.



Based on the LPA’s observations, interviews, and records review, the following deficiencies listed on the attached LIC 809D (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.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
VISIT DATE: 10/08/2021
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A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Flora Yuan.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on at 10:53 a.m., LPAs inspected off-limit kitchen area. LPAs observed clutter, flies, open food items, and expired food items sitting out on kitchen counter and on kitchen table. Pictures were taken. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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Per Licensee, will organize and deep clean kitchen area, along with remove all spoiled food items and clutter. Per licensee, will submit pictures via mail of kitchen and complete the Family Child Care Orientation online and submit certificate of completion by the due date 10/11/2021.
Type B
Section Cited
CCR
102417(g)(9)(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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) 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:
Deficient Practice Statement
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Based on Licensee did not have proof of completed fire or earthquake drill logs. Per Licensee, does not have a log. Per Licensee, does not conduct regular fire or earthquake drills, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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Per licensee, will conduct a fire and earthquake drill by the due date of 10/13/2021, and submit drill log via mail to LPA.
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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations at 10:39 a.m., LPAs observed 2 cribs. One crib had one blanket, one soft toy, and a crib liner (non-mesh). The other crib observed had a mesh crib liner partial detached to the crib. The licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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Licensee immediately removed loose items from both cribs. Per licensee, will read all Safe Sleep Regulations and complete a declaration regarding obiding by all regulations.
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
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Based on during record review, at 12:00 p.m., LPAs observed 3 out of 6 children missing proof of the LIC 700 Identitfication and Emergency Information form in the children's files. Child #2, Child #4, and Child #5 are missing LIC 700 form. Child #3 has partial completion of LIC 700 form, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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2
3
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Per Licensee, will have Child #2-5 complete the LIC 700 form and mail LPA copies of completed forms by the due date of 10/13/2021.
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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

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 record review, the licensee did not comply with the section cited above in that at 12:00 p.m., LPAs observed 6 out of 6 children missing the Parent's Rights form (LIC 995) from the all child files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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2
3
4
Per Licensee, will submit copies via mail of every child enrolled LIC 995 form, complete by the child's parents by the due date of 10/13/2021.
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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 9 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LIU & YUAN FAMILY CHILD CARE
FACILITY NUMBER: 198019893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that at 12:05 p.m., LPAs observed 6 out 6 children missing affidavit for Liability Insurance in each child's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
1
2
3
4
Per licensee, will have each child enrolled complete the LIC 282 Liability form or provide proof of liability insurance via mail by the due date 10/13/2021.
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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9