<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304371253
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:35:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
09/16/2024 and conducted by Evaluator Archibaldo Silva
COMPLAINT CONTROL NUMBER: 06-CC-20240916104935
FACILITY NAME:APPLE TREE PRESCHOOL & KINDERGARTENFACILITY NUMBER:
304371253
ADMINISTRATOR:PERANCULLO, MARBENFACILITY TYPE:
830
ADDRESS:2211 WEST WOODLEY AVENUETELEPHONE:
(714) 772-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:30CENSUS: 7DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Director Chamila GardiwasamTIME COMPLETED:
03:34 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Alleging the staff did not report scratch-like marks on the child's lower back, which resulted in
A child's needs were not met, which resulted self-induced injuries while in care.
The staff did not provide a licensing report documenting the Type A deficiency to the parents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/15/2024 Licensing Program Analyst (LPA) A. Silva conducted an unannounced complaint investigation inspection. This is a continuation of the investigation initiated on 9/20/2024. Upon arrival, the LPA met with Director Chamila Gardiwasam and informed the director of the purpose of the visit. A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance. The census at the time of the visit was 07 infants.

The Department received a complaint on 9/16/2024 alleging the staff did not report scratch-like marks on the child's lower back, a child incurred unexplained injuries at the facility, and the staff did not provide a licensing report documenting the Type A deficiency to the parents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
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 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
According to the report and an interview with the reporting party (RP) on 9/20/24, the facility staff did not inform the parents that Child #1 (C1) had scratch-like injuries on their lower back. RP stated the parents inquired about the marks on 9/16/24 and a staff member told them they heard about scratches but did not know what happened. RP also reported that staff forced parents to sign an LIC9224 without providing a copy of a report.

Allegation: The staff is not adhering to reporting requirements.

On 9/20/2024, the LPA interviewed seven staff members. Staff #3 (S3) disclosed he/she noticed a rash “near [C1’s] tailbone” when S3 changed C1’s diaper on Friday, September 13th. S3 added “I assumed it was eczema, so I just asked the teacher. I applied ointment because it was just an itching type of rash. [C1] was scratching it.” LPA asked S2 who changes diapers. S2 stated, "S1, me, S3, and S4 in the morning." S1, S3, and S4 stated that they did not see anything, or were unaware of any rash or scratches. The LPA asked the director whether the parents were informed about the rash before 9/16/24 when they confronted the staff. The director admitted that facility staff did not report the rash to the parents.

On 9/25/2024, the LPA called eight parents requesting an interview. Parents #1 (P1), P2, and P4 were reached and interviewed. The parents interviewed did not provide any information relevant to any of the allegations The rest of the parents couldn’t be reached or did not return the Department’s request for an interview.

Children were not interviewed because they were non-verbal due to their young age.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
Allegation: A child's needs were not met, which resulted self-induced injuries while in care.

On 9/20/2024, the LPA interviewed seven staff members. S3 disclosed he/she observed C1 scratching a rash on the lower back, so S3 applied ointment and left work before noon, leaving C1 under the supervision of other staff. S3 disclosed, “I assumed it was eczema and [C1] was scratching it. I don’t know what it was but Monday it turned brown.” S2 stated that C1 was not observed scratching before or after the rash was identified. S2 added that S1 informed her/him that C1 was scratching. S3 and S6 denied that C1 was injured or that anyone hurt C1 at the facility. During the interview, the director showed the LPA a recording of C1 scratching his/her lower back while in care. When asked what the staff had done to prevent C1 from scratching excessively as shown on the video, the director said nothing was done because the director learned about it on 9/16/24, at which time the director began communication with the parents. The rest of the staff interviewed did not have information about the origin of the injuries on C1’s lower back or stated they did not know anything about the incident.

On 9/20/24, the reporting party provided two pictures of injuries on C1’s lower back. The pictures show two types of scratch-like marks on C1’s lower back. The first type looks reddish like fresh scratches on C1’s skin. The second type looks brown like older, healing scratches on C1.

Allegation: staff did not provide a licensing report documenting a Type A deficiency to the parents.

On 9/20/24, the LPA requested a copy of the enrollment packet the administration gives parents when they wish to enroll a child in the infant care center. Upon reviewing the packet, the LPA observed two LIC9224 Acknowledgement of Receipt of Licensing Reports forms were included in the enrollment packet for parents to sign.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
On 9/20/24, the LPA interviewed the director about the allegation above. The LPA asked whether the licensing report(s) documenting Type A citations and the LIC9224 Acknowledgement of Receipt of Licensing Reports were given to the parents. The director stated she added the LIC9224 to the enrollment packet for the parents. LPA asked if the licensing reports documenting Type A citations associated with the LIC9224 were also given to the parents. The director said “no.”

As part of the interview with the director, the LPA and the director reviewed infant files. The LPA observed nine infant files did not have the required LIC9224 or were missing a signature on the LIC9224 citing a type A dated 6/11/2024. The director stated she was new to the center and was working on correcting existing deficiencies, including children’s files.

The LPA offered Technichal Support (TSP) to Director Chamila. The director agreed to participate in TSP. The LPA will complete a referral.

Based on the LPA’s observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A substantiated finding means that the complaint is substantiated, and the allegations are valid.

California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101229(a) Responsibility for Providing Care and Supervision 101212(f) Reporting Requirements, HSC 1596.8595(c)(1) Posting licensing report are being cited during today’s inspection. Please refer to attached LIC9099D for documentation of deficiencies.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
09/16/2024 and conducted by Evaluator Archibaldo Silva
COMPLAINT CONTROL NUMBER: 06-CC-20240916104935

FACILITY NAME:APPLE TREE PRESCHOOL & KINDERGARTENFACILITY NUMBER:
304371253
ADMINISTRATOR:PERANCULLO, MARBENFACILITY TYPE:
830
ADDRESS:2211 WEST WOODLEY AVENUETELEPHONE:
(714) 772-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:30CENSUS: 7DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Director Chamila GardiwasamTIME COMPLETED:
03:34 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
authorized representatives are denied entry into the childcare center.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/15/2024 Licensing Program Analyst (LPA) A. Silva conducted an unannounced complaint investigation inspection. This is a continuation of the investigation initiated on 9/20/2024. Upon arrival, the LPA met with Chamila Gardiwasa and informed the director of the purpose of the visit. A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance. The census at the time of the visit was 7 children.

The Department received a complaint on 9/16/2024 alleging authorized representatives are denied entry into the childcare center.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
According to the report and an interview with the reporting party (RP) on 9/20/24, authorized representatives are not allowed to enter the facility. Instead, they have to ring the doorbell and wait for assistance at the door.

Allegation: Authorized representatives are denied entry into the childcare center.

On 11/15/24, the LPA interviewed five facility staff present in the facility. The director stated that parents are asked to ring the doorbell because infants are crawling inside the daycare and they want to protect infants health and safety. The director stated that while parents are asked to ring the bell, they are not denied access. Staff #4 (S4) and S8 stated that parents are not allowed to walk in and per center regulation they are asked to ring the bell and wait outside, however the door to the infant room is kept unlocked. S9 and S10 stated parents are allowed to walk in and that they have walk ins all the time.

On 11/15/24, the LPA checked the infants room door during today’s visit. The LPA observed the door was unlocked and nothing prevents parents or guardians from entering the room. A gate was place at the entrance of the infant care room to prevent visitors from walking into the space where infants crawl. Visitors are asked to wear shoe covers before entering the infants ‘crawling area to protect the health of the infants.

On 9/25/2024, the LPA called eight parents requesting an interview. Parents #1 (P1), P2, and P4 were reached and interviewed. The parents interviewed did not provide any information relevant to any of the allegations The rest of the parents couldn’t be reached or did not return the Department’s request for an interview.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
On 9/20/25, the LPA received a video recording of about 3 minutes long. The recording shows the RP ringing the bell at the infant care center. A staff member answered the door. RP asked for Child #1 (C1). The staff asked RP to wait and shut the door. RP waited outside for approximately 1.5 minutes before the staff returns. Toward the end of the recording, the RP and a companion are observed entering the infant care center. The recording also shows other authorized representatives ringing the bell and waiting for a staff member to retrieve their children.

Children were not interviewed because they were non-verbal due to their young age.

Based on the interviews conducted and records review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Chamila Gardiwasam. The Notice of Site Visit was posted during the visit. The director 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. The director 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 to the address listed above.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
CCR
101229(a)
1
2
3
4
5
6
7
101229(a) Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
The director stated she will document the services provided to infants to provide parents a copy and keep a copy in the facility. The director will send evidnce of the documentation to the LPA by 11/20/24.
8
9
10
11
12
13
14
Based on staff interviews. S3 disclosed he/she observed C1 scratching and applied ointment and left work before noon leaving the child under the supervision of staff who did not meet C1’s needs. The child incurred injuries. This poses an immediate risk to the health, safety, or personal rights of children in care.
8
9
10
11
12
13
14
THE DIRECTOR REFUSED TO SIGN THIS CITATION PAGE.
Type B
11/15/2024
Section Cited
CCR
101212(f)
1
2
3
4
5
6
7
101212(f) Reporting Requirements. Each licensee or applicant shall … reports as required by the Department … (f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
The director stated that staff will be required to document and report incidents to report to the licensing department and to the parents as required. The director will brief the teachers about the protocol to report and provide proof to the LPA including the topcis discussed and a list of staff who participated.
8
9
10
11
12
13
14
Based on records and interviews, the staff did not report C1’s condition. Staff admitted they did not report as required. This poses a potential risk to the health, safety, or personal rights of children in care.
8
9
10
11
12
13
14
THE DIRECTOR REFUSED TO SIGN THIS CITATION PAGE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2024
Section Cited
HSC
1596.8595(c)(1)
1
2
3
4
5
6
7
HSC 1596.8595(c)(1) … reports to be provided to parents or guardian … facility shall provide to the parents … 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 …
This regulation was not met as evidenced by:
1
2
3
4
5
6
7
The director stated she will give parents a copy of appropriate licensing reports and get their signatures on LIC9224. The director will send poof of correction to the LPA by the due date.
8
9
10
11
12
13
14
Based on interview statements and records review, the facility administration failed to give parents copies of one or more licensing reports that document a Type A citation. Upon records review, the LIC9224 forms were missing or unsigned. Staff admitted they did not provide the required reports to parents. This represents a potential risk to the health, safety, or personal rights of children in care.
8
9
10
11
12
13
14
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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 06-CC-20240916104935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253
VISIT DATE: 11/15/2024
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
Director Chamila Gardiwasam was informed that this licensing report dated 11/15/2024 documents one “Type A” citation. Type A citation(s) must be posted for 30 consecutive days during the hours that children are in care as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. LPA A. Silva further informed the director that a copy of this licensing report must be provided to parents or guardians of all clients currently enrolled by the next business day or by the next day the children are in care, a copy of this report must be provided to the parents or guardians of all newly enrolled clients for 12 months from the date of this report, and signed Acknowledgement of Receipt of Licensing Report (LIC 9224) form, or another written equivalent statement, must be placed in the child's file for verification of receipt of the report.

An exit interview was conducted with Chamila Gardiwasam. The Notice of Site Visit was posted during the visit. The director 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. The director 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 to the address listed above.



THE DIRECTOR REFUSED TO SIGN THE REPORT.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 10