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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209207
Report Date: 08/27/2026
Date Signed: 08/27/2026 06:00:50 PM

Document Has Been Signed on 08/27/2026 06:00 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:YOUR LOVED ONES MATTER LLCFACILITY NUMBER:
157209207
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, ISAIFACILITY TYPE:
740
ADDRESS:4804 KENNY STTELEPHONE:
(661) 735-3236
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 2DATE:
08/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Assistant Administrator Raquel Jimenez TIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 08/27/2026, Licensing Program Analysts (LPAs) H Vang and M Vega arrived unannounced to conduct the Annual inspection. LPAs met with Assistant Administrator (AAD) - Raquel Jimenez and Staff 1 (S1). LPAs toured facility with S1 and AAD. There were two residents present at the time of visit, none are currently enrolled in day programs. Residents were resting in their rooms.

During this inspection of the facility, the following was noted: Resident rooms were clean and contained required furnishings and lighting, However central ceiling fan in Room 4 was missing a blade. Window screens were present in every bedroom and were in good repair. LPAs observed required items in the two bathrooms with hot water measuring within regulatory requirements. Resident hygiene supplies were properly stored and available.

The kitchen was toured and observed in good repair. Sharps/knives were improperly locked and stored in a kitchen cabinet accessible to residents in care. Emergency food and water supply stored in hallway closet along with overflow of non-perishable food items, Included food improperly stored some with freezer burn and other with no labels, carrots were sprouting. LPAs noted 2 days of perishable food and 7 days of non-perishable food. Menu posted on refrigerator and alternative menu items available. There are no residents with special dietary needs at this time.

Medications are centrally stored and locked in hallway closet, closet doors missing knobs. Medication dispensing records stored and locked with employee and resident files. First aid kit contains required items and is located in hallway closet with medication.

Continuation on LIC 809C

Shawna Doucette
Hou Vang
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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 18
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 03:14 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out 2 files reviewed S1 was missing TB test, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator assistant will have S2 complete TB screen by 08/28/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 03:14 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 5 missing ceiling fan blade in room # 4, sliding door not closing properly in room #2, missing knobs on linen closet, and siding under the kitchen window in front of home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Administrator assistant will send updates of all correction by 09/03/26.
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 Paper Towels not available for residents in care only a common towel, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Administrator assistant will purchase a hand dryer or a paper towel dispenser.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 03:14 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)(1)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 stove knobs were not removed from stove during LPAs Inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Administrator assistant will update LPA on resident admission agreement forms via e-mail.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 objects (chicken with produce, tortillas with frezer burn, bowl of fruit with no lid, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Buy storage containers, lable storage containsers, and check every other day to make sure everyting is in order.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
Page: 5 of 18
Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 03:14 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(b)(1)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 Staff files did not have the requred trainings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Administrator assistant will complete trainings as soon as possible and submit certification of completion to LPA via e-mail.
Administrator assistant will have Staff 2 (S2) complete trainings as soon as possible and submit certification of completion to LPA via e-mail.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 front door had lock in top left corner which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Administrator assistant will remove locks on exterior doors or perimeter fence gates. Administrator assistant will send video to LPA to show proof.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
Page: 6 of 18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207
VISIT DATE: 08/27/2026
NARRATIVE
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Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Outside physical plant issues include the following: electrical box with wires exposed, fire access gate non operational, and in front of house severe damage to exterior facia under kitchen window.

Fire Extinguisher located in the kitchen was serviced on 08/04/2026. Smoke detectors in hall, kitchen and bedrooms were tested and Carbon Monoxide detector in hallway were tested -all were found to be operational.

LPA reviewed 2 resident files and 2 staff files. Items were missing from both- see attached deficiency page for documentation of violation.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE)

LIC 308 Designation of Facility Responsibility

LIC 309 Administrative Organization

LIC 400 Affidavit Regarding Client/Resident Cash Resources

LIC 402 Surety Bond

LIC 500 Personnel Report

LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly

LIC 9020 Register of Facility Clients/Residents

Copy of current Liability Insurance

Copy of current Administrator Certificate

Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 09/10/2026

As an operator of a Community Care Licensed facility, it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed by Assistant Administrator. A copy of this report and Appeal Rights were discussed and left with AAD , whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Hou Vang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
Page: 16 of 18
Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 03:59 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bottle of bug spray and Knifes were not locked and secured from residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2026
Plan of Correction
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Administrator assistant will lock bug spry in garage.
Administrator assistant will lock knives in drawers.
Type A
Section Cited
CCR
87208(a)(7)(A)
(7) Sketches, showing dimensions, of the following:

(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 5 rooms are not being used for their intended purpose per the plan of opperations, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator assistant will submit a step by step plan to correct deficiencies via e-mail.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 06:00 PM - It Cannot Be Edited


Created By: Hou Vang On 08/27/2026 at 04:18 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC
FACILITY NUMBER: 157209207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement was not met as evidence by: LPA observation the licensee did not comply with the section cited above in that gate used as fire exit on the facility property is not able to open freely. This poses an immediate health safety and or personal rights risk to residents in care. *** An immediate civil penalty in the amount of $500 assessed. ***
POC Due Date: 08/28/2026
Plan of Correction
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Adminisrtator assistant will have brother clear the clogged linens on vent from dryer.
Administrator assistant will have brother fix the gate.
Administrator assistant will remove locks on the back door and front door.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Hou Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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