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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 02/13/2024
Date Signed: 02/13/2024 05:46:28 PM


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ANGEL CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 3DATE:
02/13/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Ding Wang, AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 2/13/2024 at 12:20pm, Licensing Program Analyst (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint (15-AS-20240212113726). LPAs met with Ding Wang, Administrator and explained the reason for the visit.

During the health and safety check LPA toured the facility with the Administrator including but not limited to common areas, bedrooms, back yard, and kitchen. Upon arrival LPA observed S3 was not associated to the facility. A bottle of medicine was sitting on the table and the medicine cabinet was unlocked.

The following deficiencies were observed during the check:
  • At 9:40am, LPAs observed S3 was not associated and during record review that R3 was not fingerprint cleared.
  • At 9:40am, LPAs observed medicines were in unlocked closet and there was a bottle of Tylenol sitting on the kitchen table.
  • At 9:55am, LPAs observed unlocked kitchen drawer containing knives, a bottle of S2 medication in unlocked kitchen cabinet, and a pair of scissors sitting on kitchen counter top in utensil dryer.
  • At 10:05am, LPAs observed rotting fruit sitting on kitchen table and rotting vegetables in refrigerator. Facility did not have a 7-day supply of non-perishables and 2-day of perishables for the residents.


Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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 11


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 02/13/2024
NARRATIVE
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Continued from LIC809.
  • 10:40am, LPAs observed R2, R3, and R4 resided in ambulatory rooms per fire clearance.
  • At 10:45am, LPAs observed hot water temperature in residents' shared bathroom measured at 133.5 degrees F. and Ajax and Windex under unlocked bathroom cabinet.
  • At 10:50am, LPAs observed via interview and record review S1 did not report any deaths, hospitalization's, or positive COVID incidents.
  • At 10:50am, LPAs observed during via interview and record review that S1 did not notify CCLD of hospice residents.
  • At 10:50am, LPAs observed facility did not obtain a hospice care plan for R3 and R4.
  • At 10:50am, LPAs observed during record review that staff files were incomplete and not current.
  • At 10:50am, LPAs observed during record review that resident files were incomplete and not current.
  • At 11:00am, LPAs observed during record review that there were not any training records for staff in files.
  • At 11:30am, LPAs observed during record review that the medication administration record (MAR) did not match the medications that were given to R2. MAR for R3 has not been updated since 2/3/2024. There was not a MAR for review for R4.
  • At 11:40am, LPAs observed Administrator was not meeting the qualifications and duties of an Administrator as specified in the regulation 87405.


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 02/13/2024
NARRATIVE
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Continued from LIC809C.

An immediate $2000.00 civil penalty will be assessed on today's date for the following:

Exit interview conducted. A copy of the LIC421FC, LIC421M, LIC421BG, this report, and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87202(a)(1)

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87202(a) All facilities shall maintain a fire clearance approved by the city, county... department, or district providing fire protection services... Prior to accepting or retaining... licensee shall notify the licensing agency and obtain an appropriate fire clearance...
(1) Non ambulatory persons.
This requirement was not met as evidence by:
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Administrator agreed to either move residents to non-ambulatory or submit updated facility sketch and LIC200 to have a new fire clearance to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in have 3 non-ambulatory residents in ambulatory rooms, which poses a potential health and safety risk to persons in care.
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Type A
02/14/2024
Section Cited
CCR87355(d)(3)

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87355 (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidence by:
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Administrator agreed to get S3 fingerprinted and submit proof to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement was not met as evidence by:
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Administrator locked knives away making them inaccessible to residents. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in having knives and scissors accessible to residents, which poses/posed an immediate health and safety risk to persons in care.
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Type A
02/14/2024
Section Cited
CCR87303(

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87303 (e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents... Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement was not met as evidence by:
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Administrator agreed to adjust water temperature between 105 - 120 and submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in have hot water between 105-120, which poses/posed an immediate health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87465(h)(2)

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87465 (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidence by:
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Caregiver locked put away medication and locked closet immediately during visit. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited in have medications locked and inaccessible, which poses/posed a potential health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 6 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
87211(a)(1)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by:
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Administrator agreed to submit incident reports/death report for R1, R4, and R5 to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in reporting incidents to CCLD, which poses a potential health and safety risk to persons in care.
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Type B
02/20/2024
Section Cited
CCR87632

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87632 (d) ...a hospice care waiver it shall stipulate terms and conditions of the waiver... to ensure the well-being of terminally ill residents... which shall include..., the following requirements: (2)The licensee shall notify the Department in writing within five working days of the initiation of hospice care... or within five working days of admitting a resident already receiving hospice care services...
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Administrator agreed to submit a hospice notification for R3 and R4 to CCLD by POC date.
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This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in notifying CCLD about hospice residents, which poses a potential health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 7 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
877405(a)

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87405 (a) All facilities shall have a qualified and currently certified administrator...The administrator shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility... When the administrator is not in the facility, there shall be coverage by a designated substitute... This requirement was not met as evidence by:
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Administrator agreed to review regulation 87405 and submit a self-certification that the regulation have been reviewed and the facility will abide by the regulation going forward to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above by not having adequate attention to the management and administration of the facility , which poses a potential health and safety risk to persons in care.
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Type B
02/20/2024
Section Cited
CCR87412(a)

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87412 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 was not met as evidence by:
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Administrator agreed to complete all personnel files and have them available for review, and will submit Health screenings, First aid, and TB test to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having all personnel records complete and current, which poses a potential health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 8 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
87506(a)

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87506 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not met as evidence by:
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The administrator agreed to complete all resident files and submit a copy of the physician's report, admission agreement, and the appraisal needs and services plan for each resident to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in have complete and current records for residents, which poses a potential health and safety risk to persons in care.
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Type B
02/20/2024
Section Cited
CCR87555(b)(26)

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87555 (b) The following food service requirements shall apply: (26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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Administrator agreed to purchase food and submit photo and receipts to CCLD by POC date.
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This requirement was not met as evidence by:
Based on observation the Licensee did not comply with the section cited above in have 1 week perishable and 2-day non perishable foods for residents, which poses a potential health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 9 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
87411(c)

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87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidence by:
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Administrator agreed to have all staff with required training and submit certifications to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having annual training for staff, which poses a potential health and safety risk to persons in care.
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Type B
02/20/2024
Section Cited
CCR87633(a)(4)

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87633 (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon... to reside in the facility and receive hospice services from a hospice agency... (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident...
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Administrator obtain the hospice care plan for R3 and R4 during visit. Deficiency cleared during visit.
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This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having a hospice plan for R3 and R4, which poses a potential health and safety risk for 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 10 of 11


Document Has Been Signed on 02/13/2024 05:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
87465(h)(6)

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87465 (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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Administrator agreed to review and correct the MAR for each resident for the month of February and submit a copy to CCLD by POC date.
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This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having the medication administrator record (MAR) current and aligned with resident's medication, which poses a potential health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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