304205597-2-27-2020-06-CC-RLOZ-BMT439-20200317184419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304205597
Report Date: 02/27/2020
Date Signed: 02/27/2020 07:24:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2020 and conducted by Evaluator Ryan Joseph Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20200129084602

FACILITY NAME:	LENZINI, JEANETTE		FACILITY NUMBER:	304205597
ADMINISTRATOR:	LENZINI, JEANETTE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 594-0247
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	14	CENSUS: 12	DATE:	02/27/2020
		UNANNOUNCED	TIME BEGAN:	02:22 PM
MET WITH:	Licensee, Jeanette Lenzini		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Operating over capacity

INVESTIGATION FINDINGS:

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

On February 27, 2020, at 2:22pm, Licensing Program Analyst (LPA) Ryan Chan and Licensing Program Manager (LPM) Rina Lopez conducted a follow up complaint investigation on an initial investigation conducted on 02/10/20 to deliver findings for the facility operating over capacity allegation received on 01/29/20.

Upon arrival today, LPA and LPM met with licensee, Jeanette Lenzini who allowed LPA and LPM entry into the facility. Licensee was caring for 8 children 3 of whom were infants and 5 preschool age children. Most of the children were in the living room (child-care area), one of the infants was napping in the napping room and was immediately removed from the napping bedroom and taken to the living room area where all the other children were watching TV. At 2:32pm Assistant, Rocio Lopez arrived at the facility with 4 additional children; 2 school age and 2 preschool age children. LPA and LPM also observed one of the infants in a baby bouncer, this item is prohibited in child-care facilities.

Continued on page

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

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

LIC9099 (FAS) - (06/04)

Page: 1 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 2

A review of the Facility Personnel Report Summary on this date (02/27/20) indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the investigation on 02/10/20, LPA Ryan Chan and LPM Rina Lopez interviewed three school aged children, Licensee, and Assistant, Rocio Lopez, and reviewed unusual incident reports, Children’s Roster, and facility sign-in sheet.

The complainant alleged the Licensee was operating over the licensed capacity. Complainant stated Licensee had between 11 or 12 during drop off with just the Licensee watching the children. Interviews conducted on 02/10/20 with the Licensee, Assistant, Rocio Lopez, and three school age children revealed both Licensee and Assistant, Rocio Lopez watch the children in care. Interviews with parents conducted on 02/03/20 and 02/04/20 also revealed the Licensee and Assistant, Rocio are there during drop off and pick up of the children. Licensee has a large daycare license and can operate with up to 14 children if an assistant is present.

During an unannounced complaint investigation conducted on 02/10/20 at 1:38 p.m., LPA and LPM observed 13 children present at the facility which included 3 infants, 7 preschool, and 3 school-age children. Interviews conducted on 2/10/20 with the Licensee and assistant revealed Assistant, Rocio Lopez left the facility to pick up three school-age children at approximately 12:30 p.m. on 02/10/20. Licensee stated assistant took two preschool children and one infant to pick up three school age children; leaving Licensee to care for 7 children. During the investigation, LPA reviewed Children’s Rosters dated 06/20/19 and 02/13/20 which revealed that when LPA and LPM were at the facility on 02/10/20, there were children enrolled that were not on the Children’s Roster dated 06/20/19. The Children’s Roster was not updated at the time when LPA and LPM were at the facility on 02/10/20.

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 3

Based on Licensee’s statement and current children’s roster, the facility was over capacity on 02/10/10 when Licensee was caring for 2 infants and 5 preschool age children without an assistant. By not having an assistant present and Licensee needed to revert to a small family child-care license which would only allow for up to 6 children if no school age children are present. Based on the review of the children’s roster the facility is being cited today for Staffing Ratio and Capacity Regulation Section 102416.5(e). The age group was not determined during the 2/10/20 investigation visit due to children’s roster not being current.
LPA and LPM interviewed Assistant, Rocio Lopez on 02/10/20 regarding capacity. Assistant stated she assist at the facility and the facility is within ratios. Assistant stated she picks up children from school and on 2/10/20, she took two children, an infant and a preschool age child to pick up three school age children leaving the Licensee with 8 children, none school aged.

During today’s follow up complaint investigation, LPA and LPM arrived at the facility at 2:22 p.m. and observed Licensee caring for 8 children, 3 of whom were infants and 5 preschool age children, no assistant present. Licensee stated Assistant, Rocio Lopez was picking up one school age child and had taken 3 children with her. At 2:32 p.m. Assistant Rocio Lopez arrived at the facility with four additional children; 2 school age and 2 preschool age children.

Licensee was given the incorrect capacity requirements and stated she was going off that. A copy of the capacity requirement dated 10/20/11 was provided by licensee to LPA and LPM. The correct capacity requirement was provided to licensee by LPA and LPM on 02/27/20.

Based on LPA’s and LPM’s observations on 02/10/20 and 02/27/20, interviews conducted on 02/10/20, and children’s roster dated 06/20/19 and 02/13/20, the Licensee failed to meet staffing ratio for a family childcare home. This poses an immediate risk to the safety of children in care. Once assistant leaves and no other assistants are present, license automatically reverts to staffing and capacity ratios for a small family childcare home. When caring for more than 6 children, one child must be at least six years of age and another enrolled in and attending kindergarten or elementary. Licensee did not have another child enrolled in or attending kindergarten or elementary at the time her assistant left to pick up the three school age children.

Continued on page 4

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 4

Therefore, the preponderance of evidence standard has been met, the allegation of facility operating over capacity is found to be substantiated. California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102416.5(e) Staffing Ratio and Capacity is being cited on the attached LIC 9099D. A civil penalty of $250.00 is being issued today as this has been cited twice within the last 12 months.

102416.5 Staffing Ratio and Capacity (e) If no assistant provider is present at a Large Family Child Care Home, then the Licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

Licensee was cited on 06/20/19 and 10/28/19 for 102416.5 (e) Staffing Ratio and Capacity. Licensee will be invited to the office for a Non Compliance Conference with management.

This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/27/2020 Section Cited CCR 102416.5.(e)	1 2 3 4 5 6 7	102416.5 Staffing Ratio and Capacity. (e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she will have the correct amount of kids. When Rocio leaves the facility to pick up children, a substitute assistant will be present. A statement from the licensee will be sent to LPA.
	8 9 10 11 12 13 14	Based on children's roster dated 06/20/19 and 02/13/20, the facility has been over capacity during children's pick up time from school. Licensee was left alone with 7 children on 02/10/20, none school age and today, licensee was caring for 8 children without an assistant and no school age chldren. This was cited on 06/20/19 and 10/28/19.	8 9 10 11 12 13 14	A civil penalty of $250.00 is being issued today.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2020 and conducted by Evaluator Ryan Joseph Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20200129084602

FACILITY NAME:	LENZINI, JEANETTE		FACILITY NUMBER:	304205597
ADMINISTRATOR:	LENZINI, JEANETTE		FACILITY TYPE:	810
ADDRESS:	12511 MARTHA ANN DR.		TELEPHONE:	(562) 594-0247
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	14	CENSUS: 12	DATE:	02/27/2020
		UNANNOUNCED	TIME BEGAN:	02:22 PM
MET WITH:	Licensee, Jeanette Lenzini		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unexplained bruises on child’s neck and body
Children are allowed to watch child-inappropriate shows on TV
Unknown adults watching the children

INVESTIGATION FINDINGS:

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

On February 27, 2020, at 2:22pm, Licensing Program Analyst (LPA) Ryan Chan and Licensing Program Manager (LPM) Rina Lopez conducted a follow up complaint investigation on an initial investigation conducted on 02/10/20 to deliver findings for the allegations: unexplained bruises on child’s neck and body, children are allowed to watch child-inappropriate shows on TV, and unknown adults watching the children.

Upon arrival today, LPA and LPM met with licensee, Jeanette Lenzini who allowed LPA and LPM entry into the facility. Licensee was caring for 8 children 3 of whom were infants and 5 preschool age children. Most of the children were in the living room (child-care area), one of the infants was napping in the napping room and was immediately removed from the napping bedroom and taken to the living room area where all the other children were watching TV. At 2:32pm Assistant, Rocio Lopez arrived at the facility with 4 additional children; 2 school age and 2 preschool age children. LPA and LPM also observed one of the infants in a baby bouncer, this item is prohibited in child-care facilities.
Continued on page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

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

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 2

A review of the Facility Personnel Report Summary on 02/27/20 indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

A complaint was filed on 01/29/20 alleging day care child had unexplained injuries such as bruises on neck and body and a bite mark on child’s hand. These incidents happened on different occasions. Also alleged was child’s behavior has changed in the last six months, becoming more aggressive by throwing things, and kicking. It was alleged there have been inappropriate or adult shows playing on TV when children are being picked up from the facility and there are unknown adults caring for the daycare children.

On 01/07/20, Licensee self-reported an incident stating a parent observed a child-inappropriate show (Floridama Shore) displayed on TV while children were in care at the facility. During the complaint investigation on 02/10/20 and 02/27/20 LPA and LPM observed children watching cartoons on TV.
During the investigation on 02/10/20, LPA and LPM interviewed three school aged children, Licensee, and Assistant, Rocio and reviewed unusual incident reports, Children’s Roster, and facility sign-in sheet. LPA also interviewed seven parents on 02/03/20 and 02/04/20.

On 02/10/20, the Licensee was interviewed by LPA and LPM regarding injuries at the facility. During the interview, the Licensee stated children play and sometimes children wrestle with other children at the facility. Licensee allows children to wrestle but not to the point of fighting. No children have had any injuries. Licensee was asked regarding the activities at the facility and TV programs. Licensee stated there was a parent who showed up one day to pick up her child and while she was trying to put two children on time-out, she tried changing the channels to prevent the children from watching TV and when parent came in the TV was accidentally left showing adult day time television. Licensee stated the children only watch children shows on TV, children do not watch child-inappropriate shows or adult shows. Licensee was asked who takes care of the children at the facility, Licensee stated she and her assistant, Rocio Lopez are the only ones who care for the children. Licensee stated her son and son-in-law live at the facility but do not help out.

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 3

On 02/10/20, Assistant, Rocio Lopez was interviewed by LPA and LPM regarding the above allegations. Assistant stated she started volunteering at the facility in August 2019. Assistant stated children will argue with each other but not fight and Licensee or herself will step in and help resolve the issue, time out is used if needed. Assistant has not observed any injuries on any of the day care children. Assistant was asked regarding the TV shows and Assistant stated children only watch children shows like Nickelodeon, Disney shows, and Netflix, and when not watching TV, children are playing. Assistant was asked who cares for children at the facility and assistant stated it was only Licensee and her who provide care for the children. Assistant stated her two brothers-in-law live at the facility but do not help out.

On 02/10/20, three school-aged children were interviewed, all three children liked attending the facility. Interviews revealed children will sometimes have accidents while at play but there have not been any injuries. LPA asked what activities children do at the child-care and children stated they pretend-play school, play hide and go seek, color, watch shows on YouTube or Netflix. Children watch Cinderella, Paw Patrol, The Grinch, and Disney shows like Minnie Mouse. The children were asked who cares for them at the facility, all children stated Licensee and Assistant, Rocio.

On 02/03/20 and 02/04/20, seven parents of children cared for at this facility were interviewed. Parents pick up and drop off children at different times in the morning and in the afternoon. Parents stated their children have not experienced any unusual injuries that needed to be elevated for concern. Parents were asked by LPA if they had witnessed any inappropriate material being shown on the TV during pick up and drop off, all parents denied seeing anything inappropriate when picking up or dropping off their children. Parents also disclosed Licensee will put children on time-out in a time-out chair if children misbehave, parents did not have any concerns regarding care and supervision of their child at this facility. Parents were asked who cares for their children at the facility, parents stated Licensee and Rocio are the ones who take care of the children and acknowledged they have seen Licensee’s son and son-in-law at the facility, but neither one interacted with the children in care.

Continued on page 4

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 06-CC-20200129084602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LENZINI, JEANETTE	FACILITY NUMBER: 304205597
	VISIT DATE: 02/27/2020

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
26
27
28
29
30
31
32

Page 4

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the unexplained bruises on child’s neck and body due lack of supervision, children are allowed to watch child inappropriate shows on TV, and unknown adults watch the children allegations are unsubstantiated at this time.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020

LIC9099 (FAS) - (06/04)

Page: 9 of 9