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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808202
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:53:51 PM

Document Has Been Signed on 07/23/2024 05:53 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:WATER OF LIFE PRESCHOOLFACILITY NUMBER:
364808202
ADMINISTRATOR/
DIRECTOR:		NORMAN, LESLIEFACILITY TYPE:
850
ADDRESS:7625 EAST AVENUETELEPHONE:
(909) 463-3915
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 149TOTAL ENROLLED CHILDREN: 101CENSUS: 63DATE:
07/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Leslie Norman, DirectorTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Taityana Benson and Perla Ordones conducted a required/annual inspection as part of a compliance review. A tour of the inside and outside of the facility was granted and the following was observed and/or noted:

A review of staff and children's records were conducted as part of this evaluation.
· The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization (only if changes have been made)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made)
· The following items have been posted and are updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
- Menu
· The facility is operating with the limits as stated on the license.
· Ratios are being met during this inspection
· Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards.
Aaron Ross
Taityana Benson
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/23/2024 05:53 PM - It Cannot Be Edited


Created By: Taityana Benson On 07/23/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

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 as LPAs observed several poisons/toxins such as Ant and Roach Killer, Flying Insect Killer, disinfectant sprays, and carpet adhesive in areas that were not key locked and accessible to children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee agrees to place all poisons/ toxins in key locked areas inaccessible to children in care and agrees to submit a written plan of action on how the facility will maintain compliance with the above listed regulations. The licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 07/24/2024.
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 Ross
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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Document Has Been Signed on 07/23/2024 05:53 PM - It Cannot Be Edited


Created By: Taityana Benson On 07/23/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(e)(1)
Buildings and Grounds
(e) All licensees shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water, through a pool cover or by surrounding the pool with a fence. (1) Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

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 as LPAs observed the left gate of the small baptismal pool located adjacent to the fenced preschool playground is not self-latching which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to ensure that the left gate of the small baptismal pool is self-latching according to regulations. Licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 08/13/2024.

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 Ross
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 05:53 PM - It Cannot Be Edited


Created By: Taityana Benson On 07/23/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as LPAs observed that all staff members present during the inspection did not posses proof of a current Mandated Reporter Child Care Provider's Training certificate (AB1207) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to have all staff members complete the Mandated Reporter Child Care Provider's Training (AB1207) and agrees to maintain a copy at the facility. Licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 08/13/2024.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 as LPAs observed that S5, S6, S7, S8, S9, S11, S12, S13, S14, and S15 did not have proof of either the MMR and/or Influenza vaccine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to have staff submit proof of the MMR and/or influenza vaccine and agrees to maintain proof in the facility file. Licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 08/13/2024.
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 Ross
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 05:53 PM - It Cannot Be Edited


Created By: Taityana Benson On 07/23/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as staff identified as the opening and closing staff by the Director did not posses proof of a current pediatric CPR/1st aid certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to submit proof of a current EMSA approved pediatric CPR/1st aid for their designated opening and closing staff members and agrees to maintain proof in the facility file. Licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 08/13/2024.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 as LPAs observed that S1 and S6 were missing proof of the LIC503 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to have S1 and S6 submit proof of the completed LIC503 and agrees to maintain proof in the facility file. Licensee agrees to submit proof of the Plan of Correction (POC) by the end of the business day on the POC due date of 08/13/2024.
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 Ross
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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Document Has Been Signed on 07/23/2024 05:53 PM - It Cannot Be Edited


Created By: Taityana Benson On 07/23/2024 at 04:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.808(a)(1)
(a) 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:
(1) 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
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Based on observation and interview, the licensee did not comply with the section cited above as LPAs observed several gallons of two percent milk in kitchen fridge and staff confirmed the two percent milk was given to daycare children, which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Director agrees to create a plan detailing a backup plan that is to be used whenever one percent milk is not readily available by their vendor. Director agrees to send a copy of the plan to LPA via email by the COB of 08/13/2024.
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 Ross
LICENSING EVALUATOR NAME:Taityana Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202
VISIT DATE: 07/23/2024
NARRATIVE
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· There are no weapons present at the facility as stated by Director, Leslie Norman
· There are two in ground baptismal pools, the primary baptismal pool is located adjacent to the worship center. The primary baptismal pool is enclosed with a 5 ft wrought iron fence with one gate, the gate is self-closing and self-latching. The small baptismal pool is located adjacent to the fenced preschool playground. The small baptismal pool is enclosed with a 5 ft wrought iron fence with two gates, the left gate is self-closing and not self-latching, the right gate is self-closing and self-latching. Both gates swing away from the small baptismal pool. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Present for supply drinking water in the indoor activity space
· Medications are stored where inaccessible to children
· Hazards are not stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are not locked
· All floors shall be clean and safe
· Bathrooms were observed to be safe, sanitary however, one of the urinals are not operable.
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Food preparation area is clean, free of litter, rubbish and free of rodents and other vermin
· Food is stored is protected from contamination
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· Uncontaminated drinking water shall be readily available both indoors and outdoors. The children bring water bottles, stationary drinking fountains are located indoors, and beverage cooler containing water are outside.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall, (see LIC9102)
· Sign in/Sign out record was reviewed and meets regulation requirements
· A Staff member is present with current Pediatric CPR/First Aid which expires on 06/2026
SUPERVISOR'S NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202
VISIT DATE: 07/23/2024
NARRATIVE
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· Opening staff member’s CPR/First Aid expired 07/2021 and closing staff member’s CPR/First Aid is missing.
· A review of children’s records was conducted, and records were found to be complete during this inspection.
· Disaster drills to be conducted every six months – last drill conducted 03/06/2024
· 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
· A review of staff records on 07/23/2024 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index 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
· A review of staff records indicates that all staff present meet minimum qualifications for the position for which they were hired.

LPA discussed AB 2370 and provided a copy of PIN 21-21-CCP which explains the requirement for lead testing of water. All licensed Child Care Centers operating in buildings constructed before January 1, 2010, shall test their water for lead.
For more information visit:
https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information

This facility provides Incidental Medical Services – IMS (the facility does not have a copy of the IMS plan for review during the inspection). LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
SUPERVISOR'S NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202
VISIT DATE: 07/23/2024
NARRATIVE
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- Director, Leslie Norman was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.



- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200



See LIC809-D for cited deficiencies.

LPA Taityana Benson informed Director, Leslie Norman that this report dated 07/23/2024 document(s) one 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.

Also, LPA Taityana Benson informed the Director, Leslie Norman to provide a copy of this licensing report dated 07/23/2024 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.
SUPERVISOR'S NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: WATER OF LIFE PRESCHOOL
FACILITY NUMBER: 364808202
VISIT DATE: 07/23/2024
NARRATIVE
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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.



Exit interview conducted and report was reviewed with Director, Leslie Norman.
SUPERVISOR'S NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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