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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440823
Report Date: 03/26/2025
Date Signed: 03/26/2025 01:31:54 PM

Document Has Been Signed on 03/26/2025 01:31 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BESCO GARDENFACILITY NUMBER:
011440823
ADMINISTRATOR/
DIRECTOR:		LAGUNA, ROBERT I.FACILITY TYPE:
735
ADDRESS:40242 CROCKETT STREETTELEPHONE:
(510) 226-8813
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 2DATE:
03/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rosario Mababa, Care Staff TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 03/26/2025 at 10:00 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Care Staff, Rosario Mababa, and explained the purpose of the visit. Administrator, Robert Laguna, gave authorization on the phone for staff to sign the report. The facility’s fire clearance was approved for six (6) ambulatory.

LPAs toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 139.7 degree Fahrenheit. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/19/2025. Emergency drill was last conducted on 09/08/2024.

At 10:08 AM, 2 of clients records were reviewed. At 10:42 AM, 2 staff records were reviewed. 2 of 2 have current first aid training and are associated to the facility. LPA reviewed a sample of client's medications.

Continue LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823
VISIT DATE: 03/26/2025
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/03/2025:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC610D Emergency Disaster Plan
Infection Control Plan

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 10:20 AM, LPAs observed cobwebs and dust all around the house. LPAs observed the kitchen stove and kitchen knobs filled with grease. LPAs observed the walls filled with dirty marks. LPAs observed clients' room and bathroom with odor. LPAs observed clutter such as bookshelves, portable gas stove, ladder, wooden palettes, boxes, and etc. in the enclosed patio area and backyard.
  • At 10:33 AM, LPAs observed the cleaning chemicals in the garage unlocked, Comet under the bathroom sink, and Clorox wipes in the dining table and kitchen.
  • At 10:05 AM, LPAs observed the hot water temperature measured at 139.7 degrees Fahrenheit.
  • At 10:31 AM, LPAs observed food was not properly stored and labeled. LPAs observed rotten tomato on top of the toaster next to cucumber that is not spoiled yet.
  • At 10:52 AM, LPAs observed that the LIC610D is not up to date and not completed.
  • At 10:53 AM, LPAs observed that the last emergency disaster drill was last conducted in September 8, 2024.
  • At 11:04 AM, LPAs observed unlocked medications such as Zyrtec and Neosporin ointment in the dining area.
  • At 11:08 AM, LPAs observed that there is no Infection Control Plan at the facility.
  • At 11:10 AM, during interview, LPAs observed that staff is not associated to the facility.
  • At 11:15 AM, during record review, LPAs observed that both clients did not have complete files on record.
  • At 11:20 AM, during record review, LPAs observed that S1 and S2 did not have the LIC501 Personnel Record.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Care Staff. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked cleaning chemicals in the garage, unlocked Comet under the bathroom sink, and unlocked Clorox wipes in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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2
3
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The Administrator agrees to lock the cleaning chemicals, do an in-service training with staff, and send proof to CCLD by POC date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on observation, the licensee did not comply with the section cited above in having the hot water temperature measured at 139.7 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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2
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The Administrator agrees to have the hot water temperature measured within range, do an in-service training with staff, and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on record review, the licensee did not comply with the section cited above by having unlocked medications such as Zyrtec and Neosporin ointment which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Administrator agrees to lock the medications, do an in-service training with staff, and send proof to CCLD by POC date.
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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

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 by not having the Infection Control Plan which pose a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
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Administrator agrees to create an Infection Control Plan and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on observation, the licensee did not comply with the section cited above in having cobwebs and dust around the house, the kitchen stove and kitchen knobs filled with grease, the walls filled with dirty marks, strong odor from the bathroom and client's room, C1 did not have a mattress box, and clutter such as bookshelves, portable gas stove, ladder, wooden palettes, boxes etc in the enclosed patio area and backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator agrees to clean, organize, and keep the facility well maintained. LPA will come back to the facility to verify.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 in having food not properly stored with labels and a rotten tomato on top of the toaster next to cucumber that is not spoiled yet which poses a potential health and safety risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Staff threw away the tomato during the visit. Administrator agrees to have food stored properly, labeled, and send proof to CCLD by POC date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 by not having the LIC610D up to date and completed which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Administrator agrees to complete the LIC610D and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 by not conducting emergency disaster drills since September 08, 2024 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Administrator agrees to conduct an emergency disaster drill quarterly and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80070(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 by having incomplete files for both of the clients at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Administrator agrees to complete the clients files and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2025 01:31 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/26/2025 at 12:27 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
(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 by not having the LIC501 Personnel Record for S1 and S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Administrator agrees to complete the LIC501 for both staff and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80019(e)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by having a staff that is not associated to the facility drive to doctor appointments which poses a potential health and safety risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
1
2
3
4
Administrator agrees to have the staff fingerprinted, associated to the facility, and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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