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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430757177
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:35:18 PM

Document Has Been Signed on 10/16/2023 04:35 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:DIAZ, ALICIAFACILITY NUMBER:
430757177
ADMINISTRATOR:DIAZ, ALICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
4089232085
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Alicia DiazTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sheena Chin and Licensing Program Manager (LPM) Gladys Kuizon met with Licensee Alicia Diaz, for an unannounced annual inspection. LPA and LPM explained the nature of today’s inspection to Licensee. Present during today’s inspection were the licensee and 2 kids in care in the facility. Days and hours of operation are Monday to Friday, 7am to 5:30pm. The adults that reside in the home are the licensee and the licensee's daughter. .

Observation
LPA and LPM, along with the licensee toured the inside and outside of the home. LPA and LPM observed that the licensee did not post the emergency disaster plan. The facility has 2 full charged fire extinguishers, 2A10BC. Carbon monoxide and smoke detectors are working properly. The off-limit areas inside in the home are all three bedrooms, garage, and the storage room in the back yard. Insect killer, a box of nails, a pair of scissors, and power drill were seen in the back yard and accessible to children. Glass cleaner was observed in the drawer in the dining room. Outlets were not covered in the playroom and the living room. In the kitchen, knives were in the drawer and cleaning supplies under the sink, all accessible to children. LPA and LPM observed that toys in the backyard were covered with spider webs and LPA advised the licensee to clean them. Licensee stated she had just enrolled children a month ago and was closed during the pandemic. A baby bouncer was observed stored in the backyard. No children were observed using the bouncer. LPA conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool.

continuing to page 2.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177
VISIT DATE: 10/16/2023
NARRATIVE
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Records review
The Licensee stated that she has current CPR and First Aid certifications, however, the records are not reviewable. The Licensee did not have the child abuse training certificate. The licensee didn't have the fire drills log as she had kids in care about one month ago. The licensee stated that she owns the home.

The licensee did not have the records for the 2 kids in care, the Notification of Parents’ Rights is in each child’s file, nor 15 min. sleeping check logs for infants under 2 years old. A review of staff records on 9/5/2023 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

Discussion

Supervision of children was discussed with Licensee, who understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


Continuing page 3.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177
VISIT DATE: 10/16/2023
NARRATIVE
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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: https://www.ada.gov/resources/child-care-centers/.

The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. Licensee was also provided the R&R contact information.

Deficiency
Regulatory violations were observed during the inspection. Therefore, citations were issued.

Further questions
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/inspection-process.

Exit
During the exit interview, the Licensee, Alicia Diaz, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
A notice of site visit was given and must remain posted for 30 days.
Exit interview was conducted and report was reviewed with the Licensee, Alicia Diaz.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

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 facility tour, LPA and LPM observed an insect killer, a box of nails, a pair of scissors, and power drill in the back yard and accessible to children. Glass cleaner was observed in the drawer in the dining room. Outlets were not covered in the playroom and the living room. In the kitchen, knives were in the drawer and cleaning supplies under the sink in the kitchen, all accessible to children. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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The licensee has put away these chemicals and items that could pose potential risks to children.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)
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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observations],the licensee does not have a swimming pool but has fountains. The licensee has a waiver for the fountain in the front yard but LPA observed there's another fountain in the back yard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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The licensee stated that she'll put plants in the fountain and submit the photo to the office.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the records review and interview, the licensee stated that she did not know that she needs to document her checks on infants so she did not have a sleeping log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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LPA provided a sleeping chart for the licensee. The licensee said that she'll document the checks and submit it the office by the due day.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

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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2
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4
Based on records review and interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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The LPM provided the online registration information to the licensee. The licensee said that she'll enroll and submit the certifciate to the office by the due date.
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on the interview with the licensee, the licensee stated that she has the current CPR and First Aid certificates, however, LPA and LPM were not able to review the certificates, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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The licensee stated that she'll find the current certificate for CPR and First Aid and sent to our office by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

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
1
2
3
4
Based on the interview with the licensee, the licensee did not have immunization records for kids in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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2
3
4
The licensee stated that she'll obtain the immunization records and submit it to the office by the due date.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the interview with the licensee, the licensee did not have the above mentioned forms for kids in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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2
3
4
LPA and LPM provided the form to the licensee. The licensee stated that she'll obtain the required forms and submit it to the office by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

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
1
2
3
4
Based on the iinterview with the licesee, the licensee did not have the emergency information for kids in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
1
2
3
4
The licensee stated that she'll obtain the records and submit it the office by the due date.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the iinterview with the licesee, the licensee did not have the emergency information for kids in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
1
2
3
4
The licensee stated that she'll obtain the records and submit it the office by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 10/16/2023 04:35 PM - It Cannot Be Edited


Created By: Sheena Chin On 10/16/2023 at 11:30 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DIAZ, ALICIA
FACILITY NUMBER: 430757177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
102425(j)(2)(D) states that documentations should include the date, the infant's name and 15 minute checks.
Based on the interview, the licensee did not have the aboved mentioned records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
1
2
3
4
LPA and LPM provided the licensee a infant sleep observation form. The licensee stated that she'll document the checks and send it to the office by the due date.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
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