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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192004286
Report Date: 09/04/2025
Date Signed: 09/04/2025 06:23:23 PM

Document Has Been Signed on 09/04/2025 06:23 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:WEST FAMILY CHILD CAREFACILITY NUMBER:
192004286
ADMINISTRATOR/
DIRECTOR:		WEST, VICKIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 299-2434
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
09/04/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:52 PM
MET WITH:Assistant, Tini OliverTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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On 8/26/2025 Licensing Program Analyst (LPA) Dawn Dowling arrived at 3:15 pm for an unannounced inspection and was greeted by Assistant Tini Oliver who is fingerprint cleared. Licensee was out doing school pick up and on the way back to residence. At the time LPA Dowling arrived there were 6 children in care. Assistant provided a tour of the home to LPA Dowling. The home consists of 3 bedrooms, 2 bathrooms, Living room, Dining room, Kitchen, laundry room, front and back yard. The rooms used for child care are 2 bedrooms, living room, dining room, kitchen (table where children eat their meals), and back yard. The off limit areas are the Master bedroom and bathroom and front yard. Due to time constraints LPA Dowling will come back within 2 weeks to complete the inspection. Licensee was given a notice of site visit to post for 30 days.

On 9/4/2025 LPA Dowling returned to residence to conducted an unannounced Annual Required Inspection and met with Licensee, Vickie West. The days and hours of operation are Monday through Sunday, 24 Hour care. Upon LPA Dowling arrival there were 2 children in care with Licensee and 2 assistants. During todays inspection licensee left to do a school pick up and returned with 7 children. Home is in capacity compliance.

The home consists of 3 bedrooms, 2 bathrooms, Living room, Dining room, Kitchen, laundry room, front and back yard. Licensee confirmed that the rooms used for child care are Bedroom# 1( also used as office area), bathroom #1, Bedroom#2- which is used as isolation area and for children in care overnight. Living Room, Dining Room, Kitchen ( younger children use table in kitchen to eat their meals), back yard.


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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286
VISIT DATE: 09/04/2025
NARRATIVE
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Off-limits areas are :Master bedroom , Master bathroom, laundry room and front yard. There is a home in the back that Licensee's brother resides in, children do not have access to the home.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There is a defunct fireplace in the living room and is made inaccessible as it is sealed off.

All other chemicals, sprays/chemicals for the yard are stored and locked in shed in back yard.

The fire extinguisher was purchased on 08/25/2025, 2 A:10 BC meeting regulatory requirement.. Smoke Detector and Carbon Monoxide were tested and operable. First Aid kit was complete. There is adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed.

The outdoor play area is the back yard is fenced and there are no hazards items to children in care. Capacity as specified on the license is being maintained.

LPA Dowling observed 2 children in care upon arrival, Licensee went to do after school pick up and 7 children arrived for care making capacity 9.. Licensee resides in home by herself, 2 has 2 Assistants, her brother that resides in the back home helps out when needed and all are fingerprint cleared.

LPA Dowling reviewed children’s files and observed files were complete with:

  • LIC Admission Agreement
  • LIC 700 Identification and Emergency Information
  • LIC 627 Consent for Emergency Medical Treatment
  • LIC 613A Personal Rights
  • Immunization Record
  • Infant Sleeping Chart for Infant Under 24 months of age

Not observed in children's files was the following form:

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286
VISIT DATE: 09/04/2025
NARRATIVE
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  • LIC 995A Notification of Parent's Rights

Licensee reminded to have documents listed on LIC 126 Entrance Checklist- Family Child Care Homes in children's file folders.

LPA Dowling observed following documents posted on bulletin board in office room accessible to parents:

· Facility License


· PUB 394- Notification of Parents Rights
· LIC 9148- Earthquake Preparedness
· LIC 610A- Emergency Disaster Plan
Licensee has Fire Drills-last one conducted on 08/22/2025.

Earthquake Preparedness Drill- last one conducted on 08/22/2025

LPA Dowling reviewed Licensee and Staff file the following were observed to be in files:

  • LIC 508 Criminal Record Statement
  • LIC 9052 Employee Rights
  • Proof of Immunization of Measles, Mumps, Rubella (MMR), TDap/Pertussis
  • LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
  • Current Pediatric CPR and First Aid Certificate issued on 08/15/2024 and expires 08/2026 by an approved Emergency Medical Services Authority (EMSA) Vendor for the following staff:
  • Vicki West
  • Cynthia Brown
  • Eric West.

Page 3

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286
VISIT DATE: 09/04/2025
NARRATIVE
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Staff Tini Oliver Huff has American Red Cross Certificate for Adult and Pediatric First Aid/CPR/AED issued on 05/29/2024 expire 5/2026.

LPA Dowling observed Mandated Reporter Training Certification issued on 4/11/2024 for Licensee and 3 Staff Members and 1 Floater 1 Staff Member was unable to locate their Mandated Reporter Training Certificate which will result in a Type B deficiency.



LPA Dowling did not observe TB Clearance or risk assessment for Staff, only Licensee had proof of TB Clearance in file. Licensee informed this will result in a Type B deficiency.

The following forms were not in Staff files and were given to Licensee to have staff complete and place in file:
  • LIC 501 Personnel Record.
  • LIC 503 Health Screening
Licensee given forms to make copies for staff and reminded to have forms in staff file folders.
Licensee provides meals and snacks for children in care.

Children have mats to sleep on, Licensee provides bedding for children. If a child has an accident the bedding is immediately removed and bedding is changed and washed.

Children have their own cubbies in the hallway to store their personal belongings.

Isolation area is the back bedroom if a child is sick in order to keep away from other children in care.

LPA Dowling observed children in care were in caring and nurturing environment and treated with dignity and respect.

LPA Dowling Licensee provided declination of flu shot for herself and Staff.

State law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. LPA did not observe any prohibit items in home.

Page 4

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286
VISIT DATE: 09/04/2025
NARRATIVE
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Medication :

LPA Dowling discussed medication with Licensee, currently Licensee gives over the counter medication if a child has a fever or feeling sick .The over the counter medication is kept locked up under the kitchen sink . Medication is inaccessible to children in care.

Incidental Medical Services (IMS) policy

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Criminal Record Statement Family Child Care Homes

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Type B deficiencies were cited during today's inspection (see LIC 809Ds). The Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days.

Exit interview conducted with Licensee. A copy of this report, notice of site inspection, Appeal Rights (LIC 9058), were given and explained during this inspection.

Page 5

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 09/04/2025 06:23 PM - It Cannot Be Edited


Created By: Dawn Dowling On 09/04/2025 at 05:33 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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3
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Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 09/04/2025 06:23 PM - It Cannot Be Edited


Created By: Dawn Dowling On 09/04/2025 at 05:37 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1697.622(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, observation the licensee did not comply with the section cited above in 4 out of 4 staff do not have proof of TB Clearance or Risk Assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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2
3
4
Licensee will have staff provide proof of TB Clearance of risk assessment on or before Plan of Correction date of 09/18/2025.
Type B
Section Cited
HSC
1596.8662(b)(1)
1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff do not have Mandated Reporter Traning Certificate in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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2
3
4
Licensee will have staff provide proof of Mandated reporter training and submit a copy of the certificate to LPA by the POC date of 9/18/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 09/04/2025 06:23 PM - It Cannot Be Edited


Created By: Dawn Dowling On 09/04/2025 at 06:05 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: WEST FAMILY CHILD CARE
FACILITY NUMBER: 192004286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 staff persons do not have Proof of TB Clearance or Risk Assessment in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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2
3
4
Licensee will have staff provide proof of TB Cleasrance or Risk Assessment on or before the Plan of Correction date of 08/18/2025.
Type B
Section Cited
HSC
1596.8662(b)(1)

1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 Staff Member did not have proof of Mandated Reporter training Certificate in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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2
3
4
Licensee will have Staff person provide proof of Mandated Traning Certificate on or before the Plan of Correcstion datse and will email to LPA Dowling
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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