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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334806450
Report Date: 10/13/2022
Date Signed: 10/14/2022 08:51:30 AM


Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:ESCOBAR FAMILY CHILD CAREFACILITY NUMBER:
334806450
ADMINISTRATOR:ESCOBAR, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 770-3051
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:14CENSUS: 7DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Martha EscobarTIME COMPLETED:
04:30 PM
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On date and time listed, Licensing Program Analyst (LPA) Samuel Lopez arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday through Friday, 6:00am to 6:00pm

OFF-LIMIT AREAS INCLUDE: One bedroom and backyard (temporarily)

Licensee was advised about the garage usage. Garage to be used for additional play space ONLY, not for sleeping or eating.

The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are NOT stored inaccessible to children - items, in the bath room assigned to the children in care, were accessible to the children (toothpaste, mouthwash, alcohol wipes, Lysol)
· Toxins are locked
· Weapons are not present at the facility according to the licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· The facility is a single story home
· Verification of control of property on file (Mortgage Statement)
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training completed on 10/26/2021
· Pediatric CPR and First Aid Card expired on 3/2022
· Health & Safety Certificate - completed on 11/5/1995
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450
VISIT DATE: 10/13/2022
NARRATIVE
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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster NOT on file
· Documentation of fire and disaster drills on file – Last drill conducted on 3/25/2022
· Children’s records are NOT complete
· Employee’s records are complete (previously reviewed)
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 10/13/2022 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with licensee Martha Escobar 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 Martha Escobar 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 PIN 22-02-CCP. 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

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450
VISIT DATE: 10/13/2022
NARRATIVE
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- Licensee Martha Escobar 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.

- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at: https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:


1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.

LPA Lopez informed licensee Martha Escobar that this report dated October 13, 2022 document(s) (1) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Also, LPA Lopez informed the licensee Martha Escobar to provide a copy of this licensing report dated October 13, 2022 that documents any Type A citation(s) 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.



The LICENSEE, Martha Escobar, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee Martha Escobar.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Located in the bathroom that is assigned for the children to use, there were several items (mouthwash, toothpaste, hair products) with "KEEP OUT OF THE REACH OF CHILDREN" labels that were accessible to the children. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee agrees to submit pictures showing items have been made inaccessible and a written plan as to how compliance will be maintained. Both to be submitted to the Riverside Child Care Regional Office by 10/14/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above. The last drill that was logged took place in March 25, 2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to conduct a drill, log it, and submit a copy of the log to the Riverside Child Care Regional Office by 10/21/2022.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Both, the licensee and her assistant had expired (3/2022) CPR/1st aid cards. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to enroll in an EMSA approved CPR/1st aid course and submit proof of enrollment to the Riverside Child Care Regional Office by 10/21/2022.

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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. In reviewing children records, Child #2, did not have the required record on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to obtain the required, Immunization Records, and submit a copy to the Riverside Child Care Regional Office by 10/21/2022.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. In reviewing children records, Child #2, did not have the required form LIC 995A on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to obtain a signed copy of Parents Rights LIC 995A and submit a copy to the Riverside Child Care Regional Office by 10/21/2022.

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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. In reviewing children records, Child #2, did not have the required forms LIC 700 and LIC 627 on file.This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to obtain completed/signed copies of forms LIC 700/LIC 627 and submit copies to the Riverside Child Care Regional Office by 10/21/2022.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The roster that was reviewed was not updated with dates of disenrollment and/or names of children currently in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to updated the facility roster LIC 9040 and submit a copy to the Riverside Child Care Regional Office by 10/21/2022.

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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

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
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Based on record review, the licensee did not comply with the section cited above. In reviewing children records, Child #2, did not have the required form LIC 282 on file. This which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to obtain a completed/signed copy of form LIC 282 and submit a copy to the Riverside Child Care Regional Office by 10/21/2022.
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
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3
4
Based on record review, the licensee did not comply with the section cited above. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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2
3
4
Licensee agrees to obtain a completed/signed copy of form LIC 9227 and submit a copy to the Riverside Child Care Regional Office by 10/21/2022.

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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 10/14/2022 08:51 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: ESCOBAR FAMILY CHILD CARE
FACILITY NUMBER: 334806450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and licensee's own admission, the licensee did not comply with the section cited above. Licensee had not yet began recording the 15 minute checks. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Licensee agrees to begin logging the 15 minute checks and will submit a copy of the log to the Riverside Child Care Regional Office by 10/21/2022.
Type B
Section Cited
HSC
1596.808(a)(1)

AB2084: Commencing January 1, 2012, except as provided in subdivisions (b) and (c), a licensed child day care facility shall comply with all of the following requirements for beverages served by the day care provider to children in the provider’s care: Whenever milk is served, serve only lowfat (1 percent) milk or nonfat milk to children two years of age or older.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on observation, the licensee did not comply with the section cited above. Upon entering the facility, LPA observed child eating lunch, and in the facility refrigerator was only Vitamin D Whole milk. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
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3
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Licensee agrees to purchase the milk that is required by the Health and Safety Code cited and submit proof of purchase to the Riverside Child Care Regional Office by 10/21/2022.

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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel LopezTELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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