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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:07:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230830095706
FACILITY NAME:ELEGANCE BERKELEYFACILITY NUMBER:
019201143
ADMINISTRATOR:BADOUD, ANDREWFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(951) 310-0024
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:120CENSUS: 47DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:LaTiana James/Director of Health and Wellness TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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-Staff allow a resident to be in soiled clothing for extended periods of time.
-Staff do not properly maintain resident's bedroom.
-Staff do not meet a resident's incontinence needs while in care.
-Staff did not safeguard resident's personal belongings.
-Staff do not properly maintain the facility grounds.
-Staff inappropriately removed a resident's hygiene products while in care.
-Staff did not provide adequate supervision to a resident while in care.
INVESTIGATION FINDINGS:
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At 11:40 a.m. on this day, 4/25/24 , Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Director of Health and Wellness LaTiana James, and informed the reason for visit. LPA called and left message on Executive Director Robert Coe's voicemail.

On 9/05/23, LPA Gregory Clark conducted the 10-day complaint visit. On 3/05/24, Licensing Program Manager (LPM) Jeremy Fong conducted a subsequent investigation.

During the course of investigation, LPA Clark obtained copies of resident roster and staff schedule. LPA Clark and LPM Fong toured the facility and obtained copies of residents including but not limited to the following documents: Admission Agreement; Identification and Emergency Contact Information; LIC602A Physician's Report (MD Report); Needs and Services Plan; incident reports. LPM Fong also conducted interviews.
......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 04/25/2024
NARRATIVE
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Page 2

Staff allow a resident to be in soiled clothing for extended periods of time

At complaint intake on August 30, 2023, the RP reported that on multiple occasions the RP had visited R1 and found R1 to be soaked in urine. On March 4, 2024, LPM Fong spoke with the RP who reiterated that R1 was found to be soaked in urine on multiple occasions and that this was brought to the attention of S4. On March 5, 2024, LPM Fong conducted a continuing complaint visit and observed that R1s MD report and intake Appraisal indicated that R1 was independent in toileting. On that same date, LPM Fong interviewed S2, S3, and S4 – all of whom were confirmed to have been employed during the subject time period. S2 reported having no knowledge of the issue, however, S4 acknowledged that family reported coming to the facility to find R1 soaked in urine. An internal investigation was performed, and it was determined that R1 had been left in urine soaked garments and bed for an extended amount of time. Updated Needs and Services documents from August, 2023, indicated that R1 did require incontinence undergarments and changing. Therefore, the allegation is substantiated.

Staff do not properly maintain resident’s bedroom.

At complaint intake on August 30, 2023, the RP reported that during multiple visits, R1's room was found to have urine soaked clothing and bedding strewn about and with strong urine smell. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – each stated having no knowledge of R1s room not being properly maintained, cleaned, or serviced. On March 8, 2024, LPM Fong spoke with W1 (neutral witness) who reported having visited R1 at the facility mid-morning and found the room to smell strong of urine – to the point where W1 could not stay in the room. W1 also reported that the laundry basket was full of urine soaked items and that W1 pulled the basket out of the room and requested staff to remove and launder. Therefore, the allegation is substantiated.

......continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 04/25/2024
NARRATIVE
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Page 3

Staff do not meet a resident’s incontinence needs while in care.

Per the above, at intake the RP reported that R1s incontinence needs were not being maintained. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S3 reported being on the early morning shift and on multiple occasions immediately found R1 to have been left in urine soaked clothing and bedding. S3 stated that the NOC shift had not properly checked and changed R1 as needed prior to S3’s arrival, therefore, the allegation is substantiated.

Staff did not safeguard resident’s personal belongings.

At complaint intake, RP reported that R1s undergarments and assistive walking devices had gone missing, with no explanation. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S2 and S4 reported having no knowledge any items belonging to R1 going missing. However, S3, reported that on multiple occasions staff found that R1s assistive walking device was missing – sometimes it was found, other times it was not, or was found having been destroyed. S3 confirmed that family had to purchase a new assistive walking device, therefore the allegation is substantiated.

Staff do not properly maintain the facility grounds.

At complaint intake, the RP reported visiting the facility on multiple occasions and observing urine smell in common areas. On March 4, 2024, LPM Fong interviewed S1, S2, S3, and S4 who denied knowledge of urine smell or other maintenance issues. On that same day, LPM Fong observed a strong urine smell in the common area near the secondary/back exit from Memory Care. Therefore, the allegation is substantiated.

Staff inappropriately removed a resident’s hygiene products while in care.

At complaint intake, the RP reported having visited the facility and found that all of R1s personal hygiene products had been removed from the room. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – with S2 and S4 stating that there had been staff persons who took it upon themselves to remove and lock the residents’ hygiene products. R1’s Service Plan indicated R1 is able to keep non-toxic products (hand and body soap, toothpaste, shampoo) in R1’s room Therefore, the allegation is substantiated.

.......continued on 9099C (page 4)

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 04/25/2024
NARRATIVE
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Page 4

Staff did not provide adequate supervision to a resident while in care.

At complaint intake, the RP reported that on December 5, 2023, RP found R1 half-naked and wedged between the bed and the wall and that R1 had been able to exit the facility unsupervised (from the Memory Care Unit). On March 5, 2024, LPM Fong interviewed S2, S3, and S4, with all stating having no knowledge of either incident. No witnesses were identified. On that same day, LPM Fong observed that an incident report dated April 11, 2023, was submitted to CCLD indicating that 3 residents (including R1) had been able to exit the Memory Care unit on April 5, 2023. Two of the residents were found in the stairwell; however, R1 was not observed until 15 minutes later when staff noted R1 outside of the facility. LPM Fong reviewed the MD report which confirmed that R1 could not leave unassisted. Based on information obtained, the allegation is substantiated.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of correction were discussed with the LaTiana James.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230830095706

FACILITY NAME:ELEGANCE BERKELEYFACILITY NUMBER:
019201143
ADMINISTRATOR:BADOUD, ANDREWFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(951) 310-0024
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:120CENSUS: DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:LaTiana James/Director of Health and Wellness TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff do not properly safeguard the facility grounds.
INVESTIGATION FINDINGS:
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At 11:40 a.m. on this day, 4/25/24 , Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Director of Health and Wellness, and informed the reason for visit. LPA called and left message on Executive Dire ctor Robert Coe's voicemail.

On 9/05/23, LPA Gregory Clark conducted the 10-day complaint visit. On 3/05/24, Licensing Program Manager (LPM) Jeremy Fong conducted a subsequent investigation.

During the course of investigation, LPA Clark obtained copies of resident roster and staff schedule. LPA Clark and LPM Fong toured the facility. LPM Fong also conducted interviews.

......continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 04/25/2024
NARRATIVE
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Page 2

At complaint intake, the RP reported that R1 had been able to exit the Memory Care unit and the building without supervision. RP further reported being able to exit Memory Care by pushing the door, and that it was not secure. On March 5, 2024, LPM Fong observed that the main entry to Memory Care is accessed by taking the elevator to the second floor, and that an electronic key fob is needed to release the entry/exit door. From the inside, LPM Fong again found that the key fob is required to release the door. LPM Fong found that there is a second, back door exit leading to a stairwell that exits at the ground level. This secondary door was found to be a delayed egress. During interview, S1, S2, S3, and S4 stated having no knowledge of there being a maintenance issue with the Memory Care unit doors and no other witnesses were identified. It is undetermined whether R1 had been able to exit specifically due to failure to secure the facility grounds.

Based on information gathered, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208.........
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
-This requirement is not met as evidenced by:
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Executive Director to do the following and submit proof by 4/26/24.
1. In-service the staff.
2. Informed front desk staff of residents who can not the facility unassisted.
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-Based on interviews and records review, the licensee did not comply with the section above when 3 residents in Memory Care Unit were able to leave unassisted/unnoticed which posed an immediate safety risks to persons in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence
(b) .... the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.

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Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 5/09/24.
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-This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not comply with the section above in R1 being left in urine soaked clothing for extended period of time which posed a potential health and/or personal rights risks to person in care.
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Type B
05/09/2024
Section Cited
CCR
87468.1a(2)
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87468.1 Personal Rights of Residents in All Facilities: (a)....... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

-This requirement is not met as evidenced by:
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Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.
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-Based on interviews and records review, the licensee did not comply with the section above in not properly upkeeping R1’s bedroom.which posed a potential personal rights risks to person in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities: (a)...... (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

-This requirement is not met as evidenced by
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Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.
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-Based in interviews, the licensee did not comply with the section above in not meeting R1's incontinence care needs which posed personal rights risk to person in care.
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Type B
05/09/2024
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables
(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.....
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Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.
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-This requirement is not met as evidenced by:
-Based in interviews, the licensee did not comply with the section above in not safeguarding R1's personal belogings whiich posed personal rights risk to person in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 15-AS-20230830095706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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Executive Director to do the following and submit proof by 5/09/24:
1. Ensure proper housekeeping is maintained.
2. Conduct in-service training and submit copy of training topic(s) with attendees signatures.
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-This requirement is not met as evidenced by:
-Based in interviews and observation, the licensee did not comply with the section above in facilty having strong smell of urine which pose personal rights risk to persons in care.
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Type B
05/09/2024
Section Cited
CCR
87468.1(a)(12)
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87468.1 Personal Rights of Residents in All Facilities: (a)..... (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.
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Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 5/09/24,
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-This requirement is not met as evidenced by:
-Based in interviews, the licensee did not comply with the section above when staff removed R1's hygiene items which posed a potential personal rights risk to person in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
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