304313549-4-12-2022-06-CC-CODM-CDET2P-20220412142104

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313549
Report Date: 04/12/2022
Date Signed: 04/12/2022 02:21:31 PM

Document Has Been Signed on 04/12/2022 02:21 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	FERNANDO, RASIKA		FACILITY NUMBER:	304313549
ADMINISTRATOR:	FERNANDO, RASIKA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 853-8420
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	14	CENSUS: 12	DATE:	04/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rasika Fernando - Licensee		TIME COMPLETED:	02:30 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	An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Carmen Odom. At 10:00am LPA observed licensee and 1 assistant, caring for a total of 12 children, in which were, 5 infants, 6 preschool age children and 1 school age child playing. Licensee was not operating within the licensed capacity as specified on license. Upon arrival at 10:00am, LPA Odom took census of the children present and observed 5 infants in the childcare facility, 1 infant napping and 4 infants playing in the backyard. Licensee stated, parent of Child#12 informed licensee the night before they would drop off C12 at the childcare facility for 2 hours. Parent picked up C12 at 10:35am from the childcare facility. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there is 1 adult including the licensee living in the facility. Facility Day care hours are 7:00am-6:00pm, Monday through Friday. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates and baby doorknobs. The childcare area consists of the dining room, enclosed patio, and bathroom located down the hallway on the right side. Licensee stated the children's primary area is the childcare room. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. Continue to page 2

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2022 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(d)(1)

Staffing Ratio and Capacity

(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, at 9:55am, LPA Odom took census of the children present and observed 5 infants in the childcare facility, 1 infant napping and 4 infants playing in the backyard. Licensee stated, parent of Child#12 informed licensee the night before they would drop off C12 at the childcare facility for 2 hours. Parent picked up C12 at 10:35am from the childcare facility. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will make sure they communicate with parent of C12 and inform the parent when there are 4 infants in care and child can not be dropped off. LPA Odom provided E-leanrnig Modules for licensee and staff to watch "How many children can attend a FCCH". LPA Odom will return to clear citation. Licensee will submit a written statement witn plan of correction by today.

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, Licensee stated, they are in the same room supervising the children when napping, but they have not been documenting on the napping log for all 5 infants. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will begin to document every 15 minutes on the napping log for all infants while they nap. LPA Odom provided licensee a napping log sample. Licensee will submit a copy of napping log for infants to the department by the due date.

Type B

Section Cited

CCR

102425(j)(2)(A)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Labored breathing. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, Licensee stated, they are in the same room supervising the children when napping, but they have not been documenting on the napping log for all 5 infants. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will begin to document every 15 minutes and labored breathing on the napping log for all infants while they nap. LPA Odom provided licensee a napping log sample. Licensee will submit a copy of napping log for infants to the department by the due date.

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2022 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(B)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, Licensee stated, they are in the same room supervising the children when napping, but they have not been documenting on the napping log for all 5 infants. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will begin to document every 15 minutes for signs of distress on the napping log for all infants while they nap. LPA Odom provided licensee a napping log sample. Licensee will submit a copy of napping log for infants to the department by the due date.

Type B

Section Cited

CCR

102425(j)(2)(C)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, Licensee stated, they are in the same room supervising the children when napping, but they have not been documenting on the napping log for all 5 infants. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will begin to document every 15 minutes for the position on the napping log for all infants while they nap. LPA Odom provided licensee a napping log sample. Licensee will submit a copy of napping log for infants to the department by the due date.

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2022 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on(observation, interview, and record review, during file reviews at 11:30am, 2 out of 12 children were missing immunization records. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Licensee stated, they thought parents had 30 days from enrollment to provide copies of immunization records. Licensee will obtain copies of immunization records for both children and provide a copy to the department by the due date.

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 observation, interview, record review, during file at 11:30am LPA Odom observed 1 infant under 12 months, LPA reviewed child#6 file and LIC 9227 Individual Infant plan was missing. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2022
	Plan of Correction
1 2 3 4	Licensee stated, they will provide the form to the parents of C12 to complete and return the form immediately. Licensee will provide a copy of the LIC9227 form for C12 to the department by the due date.

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
	VISIT DATE: 04/12/2022

NARRATIVE

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There is a fireplace in the living room screened by a metal cover and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use the backyard for outdoor play, LPA inspected the backyard and within compliance. There are no bodies of water on the facility. Licensee currently provides overnight care.

The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. During file review at 11:30am LPA Odom observed 1 infant under 12 months, LPA reviewed child#6 file and LIC 9227 Individual Infant plan was missing. Licensee stated, they are in the same room supervising the children when napping, but they have not been documenting on the napping log for all 5 infants. During file reviews at 11:30am, 2 out of 12 children were missing immunization records.

The licensee and assistant’s Pediatric CPR/First Aid certification expired 6/2023. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for (licensee and assistant) were reviewed and within compliance.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
	VISIT DATE: 04/12/2022

NARRATIVE

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The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA 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.

Updated face covering guidance was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
	VISIT DATE: 04/12/2022

NARRATIVE

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Important COVID-19 resources and links were provided:
· COVID-19 Update Guidance Childcare Programs/Providers link:
https://files.covid19.ca.gov/pdf/guidance-childcare.pdf
· CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Staffing Ratio and Capacity 102416.5(d)(1), Infant Safe Sleep 102425(j)(2), Infant Safe Sleep 102425(j)(2)(A), Infant Safe Sleep 102425(j)(2)(B), Infant Safe Sleep 102425(j)(2)(C), Infant Safe Sleep 102425(c) and Immunizations 102418(a) (see LIC 809D).

LPA Odom informed licensee Rasika Fernando that this report dated 4/12/2022 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Also, LPA Odom informed the licensee to provide a copy of this licensing report dated 4/12/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

Page: 9 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, RASIKA	FACILITY NUMBER: 304313549
	VISIT DATE: 04/12/2022

NARRATIVE

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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.

Exit interview conducted and report was reviewed with the licensee Rasika Fernando. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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