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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813742
Report Date: 04/13/2023
Date Signed: 04/13/2023 06:20:03 PM


Document Has Been Signed on 04/13/2023 06:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:ANDERSON COUNTRY PRESCHOOLFACILITY NUMBER:
364813742
ADMINISTRATOR:BEVERLY ANDERSONFACILITY TYPE:
850
ADDRESS:1023 PARADISE WAYTELEPHONE:
(909) 505-7112
CITY:BIG BEAR CITYSTATE: CAZIP CODE:
92314
CAPACITY:45CENSUS: 29DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Administrator, Katie Anderson TIME COMPLETED:
06:30 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
On April 13, 2023, Licensing Program Analyst (LPA) Zirbes met with the Facility Representative Katie Anderson for the purpose of conducting an unannounced required one year inspection. LPA toured and inspected the facility in accordance with the facility sketch. There were 29 preschool age children, three teachers and one aide on site. Based on LPAs observation the facility was meeting the capacity/ratio requirements during this inspection. The center operates out of a two story building. Only the first floor of the building is utilized for the preschool. The preschool has three classrooms, a kitchen, two children bathrooms, one staff bathroom and multiple closet space. The program operates Monday thru Friday 7:00am -5:30pm Indoor/Children's Area:
Child care center was toured to ensure the center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction. In the area identify as the gym LPA observed a hole in the blue wall that was approximately 3 inches wide by two inches in height. The dry wall was visible. Cots were set up against this wall. On another wall of the gym area, LPA observed approximately five one inches sections of peeling red paint. Cots were observed set up against this wall. Peeling paint was also observed in the preK classroom and in the outdoor play space. In addition LPA observed two outlets in the preK classroom and two outlets in the dining area were missing the child safety covers. Cleaning compounds were stored on shelves approximately 5 feet high and in cabinets with child safety locks. Per Licensee zero poisons are stored within the preschool. Classrooms were free of flies, other insects and rodents. The classrooms had tables and chairs to meet the children's needs. LPA observed the Center has a variety of art supplies, dramatic play equipment, books, blocks, and a wide variety of additional educational materials. During the walk thu LPA observed two sun screen bottles with labeled "keep out of reach of children" on the kitchen counter near the sliding glass door leading to the outdoor play space. All children were outside playing at the time of the observation. A pizza cutter and a bread knife were in a drawer in the kitchen. The kitchen is accessible to the children. Children were not observed in the kitchen area however were observed in the dining are approximately 10 - 15 feet away from the drawer. This is a potential risk to the children in care therefore a type B citation was issued.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742
VISIT DATE: 04/13/2023
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
Report continued from page one
Children's belongings are kept in cubbies labeled with the children's names. Trash cans for solid waste have tight fitting lids. Drinking water is readily available indoors via water bottles provided by the parents/authorized representatives. All materials and surfaces are toxic free, window screens in good repair and free of debris. There is a working carbon monoxide detector, smoke detector and multiple fire extinguishers located throughout the Center. There are two bathrooms in the preschool Center. Each bathroom has two toilets and one sink. LPA observed one of the laminate flooring material was missing from one bathroom. In addition LPA observed the flooring behind a toilet was stained brown and the flooring material was peeling. Per facility representative there was a leaky pipe in January 2023 that cause the damage. A type B citation was issued. Toilets and sinks were functioning properly and are age appropriate. LPA observed soap and toilet paper and a electric hand dryer readily available.
There was working telephone service within the preschool. There is an isolation area for children who become ill. The facility maintains a comfortable temperature at all times. LPA observed the centers sign in/out sheets, which are completed daily. Smoking is prohibited on the premises. Teachers conduct daily inspection for illnesses. LPA did not observe prohibited childcare items during this inspection. Firearms/weapons are not allowed or stored on premises. The Center provides two meals and one snack a day.
Napping
LPA observed the children sleeping on cots. LPA and ad Facility representative discussed the arrangement of the cots in the gym area.
Outdoor
LPA inspected the outdoor play space for health, safety, cushioning material, good repair and age appropriateness. The Center has two outdoor spaces, one which is currently off limits. The on limits outside activity area has bikes, tables, chairs and two climbing structures. The climbing structures are placed on artificial turf. Per Facility representative sand is under the artificial turf. Per facility representative the artificial turf was not approved by the Department as an approved cushioning material. When LPA walked on the artificial turf the material did not bounce or flex. LPA observed a climbing structure "rock wall" was within 3 feet of cement. LPA advised the Center to ensure the fall zones surrounding all climbing structures meet the manufactures requirements. Two type B citation were issued. The outdoor space was enclosed by a chain link fence that is at least four feet in height. Report continued on page three
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742
VISIT DATE: 04/13/2023
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
Report continued from page three
Facility representative was advised of the requirement to report Unusual Incidents. Facility representative informed to utilize the Unusual Incident Report/Injury Report LIC624 when submitting the report to the department (email address unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The On-Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Center shall permit the Department to inspect the child care center and to privately interview children or staff, to determine compliance with or to prevent violations of child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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 license 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.



Report continued on page five.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742
VISIT DATE: 04/13/2023
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
Report continued from page two

Water is accessible to the children via personal water bottles. Facility representative stated the required lead testing was conducted.
Health Related Services
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 Child Care Centers Sections 101173 and 101226.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

Child/Staff/Personnel Records
LPA reviewed ten child records. Two of the ten files reviewed were missing the medical assessment. LPA reviewed a total of four staff files. Based on LPA's review, two of four staff files reviewed were missing the immunization's records and health screening. Staff #2 (S2) was missing TB, Staff #4 (S4) was missing documentation of all required immunization's and health screening. Due to the missing documentation, the staff files and child files were incomplete at the time of this inspection. Two type B citations were issued for as this poses a potential risk to the children in care.

Facility Records


LPA and facility representative reviewed the LIC 311A Records To Be Maintained At The Facility. LPA observed a current roster, fire/disaster drill log (April 2023). A staff member was on site who had a current CPR/First Aid.
Posting Requirements
The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393), car seat law (PUB 269), emergency disaster plan, earthquake preparedness checklist.

Report continued on page four

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742
VISIT DATE: 04/13/2023
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
Report continued from page four

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

Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Facility Representative Katie Anderson.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 04/13/2023 06:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.3(b)
Indoor Activity Space
(b) The floors of all rooms shall have a surface that is safe and clean.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when the floor under and behind one toilet in the children bathroom was brown in color and the floor was peeling. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
1
2
3
4
Per Facility representative, we will seek advise on spot removal and either utilize tile paint or remove and replace tiles. A picture will be submitted to the Department once completed.
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when peeling paint was present on the walls of the classrooms and in the outdoor activity space. In addition four electrical outlets were missing child safety plug covers. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
1
2
3
4
Per facility representative, contact paper will be placed over the areas by 4/12/23, until a permanent solution can be remedied. Child safety covers were installed today. We will have a teacher meeting and the teachers will be required to conduct morning safety checks. Teachers will document the safety checks. Documentation of the checks and pictures will be submitted to the Department.
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 6 of 12


Document Has Been Signed on 04/13/2023 06:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when two bottle of sun screen identified as keep out of reach of children were on the kitchen counter . A pizza cutter and bread knife were observed in a kitchen drawer. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
1
2
3
4
Per Facility representative, items were relocated. This item will dicussed during the staff meeting. A copy of the staff meeting and agenda will be sent to the Department.
Type B
Section Cited
CCR
101238.2(c)
Outdoor Activity Space
(c) Equipment and activity areas shall be arranged so that there is no hazard from conflicting activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when the rock wall climbing structure was within three feet of the cement walk way. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
1
2
3
4
Per facility representative the rock wall will be moved to the off limit areas, until we can ensure the fall zone is met.
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 7 of 12


Document Has Been Signed on 04/13/2023 06:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.2(e)
Outdoor Activity Space
(e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when two climbing structures were placed on artificial turf on top of compacted sand. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
1
2
3
4
Per facility representative, licensing will be contacted to discuss cushioning material. The slides will be off limits as of 4/14/23 until cushioning material can be installed.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two of four staff files reviewed did not contain immunization's records and the Health Screening. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
1
2
3
4
Per facility representative, the staff will obtain health screening and the immunization's paperwork will be added to the files. A facility checklist for staff files will be utilized to ensure all files are complete prior to starting.
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 8 of 12


Document Has Been Signed on 04/13/2023 06:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ANDERSON COUNTRY PRESCHOOL
FACILITY NUMBER: 364813742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above when two of ten child files reviewed were missing the medical assessment. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
1
2
3
4
Per facility representative a copy of the physicians report will be added to the child's file. Upon enrollment the facility will utilize a check list to ensure all required paperwork is in the child files.
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 9 of 12