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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850126
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:15:32 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210408143441
FACILITY NAME:GOLDEN CENTURY ASSISTED LIVING INCFACILITY NUMBER:
195850126
ADMINISTRATOR:HAYRAPETYAN, VIKTORYAFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(818) 416-0506
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 3DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Tsisana "Ana" Mikia and Akhtar "Ellie" RoshanaeianTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Failure to provide staff qualified to meet residents needs
Failure to keep hazardous items inaccessible
Failure to keep medications inaccessible
Failure to provide sufficient staff to meet residents needs
Failure to keep facility safe, sanitary and in good repair
Failure to prevent use of bedrooms as passageways
Failure to prevent interference with residents access to food
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit at 10:50 a.m. The LPA was initially greeted by staff Tsisana "Ana" Mikia. The LPA spoke with owner Akhtar "Ellie" Roshanaeian at 11 a.m. and with Administrator Viktorya Hayrapetyan over the phone at 11:31 a.m. and inform them of the reason for the visit. Owner Akhtar "Ellie" Roshanaeian arrived at approximately 12:45 p.m.

During today’s visit, the LPA conducted a physical plant tour from 11:05 a.m. – 11:15 a.m., and conducted an additional tour with owner Akhtar "Ellie" Roshanaeian at 12:50 p.m. The LPA reviewed facility files at 11:20 a.m., and conducted staff interviews at 11 a.m., 11:31 a.m., and 12:47 p.m., and interviewed one out of three residents at 12:05 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 07/20/2021
NARRATIVE
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Regarding the allegation: Failure to provide staff qualified to meet residents needs
It was alleged that staff were unable to communicate effectively with residents, and staff did not meet the Criminal Record requirements necessary to work at the facility. During today’s visit, the LPA observed that Staff #1 (S1) was able to communicate with the residents and was able to address their needs. However, a credible witness noted that a previous staff person (S2) was unable to effectively communicate with residents. Interviews with the owner revealed that S2 no longer works at this facility. Yet it was communicated that S2 worked at the facility for over a month. However, during this visit S1 was observed speaking Spanish to Resident #2 (R2) in response to R2’s needs. However, interviews and records review confirmed that S1, S2, and the owner Ellie Roshanaeian were not associated to this facility. Based on the information, the allegation ‘failure to provide staff qualified to meet resident’s needs’ is Substantiated at this time.

Regarding the allegation: Failure to keep hazardous items inaccessible
It was alleged that household chemicals, cleaning products and sharp kitchen knives were observed accessible to residents in care. Upon arrival, the LPA was greeted by staff whom were in the front yard. Upon entry into the facility, the LPA observed two knives in the kitchen sink at approximately 10:59 a.m. At 11:01 a.m., the LPA observed Clorox wipes and disinfectant spray accessible. At 11:15 a.m., the LPA observed the laundry area with a lock; however, the locking mechanism was not engaged. The LPA opened the laundry doors and observed accessible laundry detergent and bleach. At the time of the observation, S1 locked up the items immediately. Throughout the visit, two out of three residents (Resident #1, Resident #2 – R1, R2) were observed ambulating unrestricted throughout the facility. Based on observation, the allegation ‘Failure to keep hazardous items inaccessible’ is Substantiated at this time.

Regarding the allegation: Failure to keep medications inaccessible
It was alleged that medications were accessible to residents. Upon entry to the facility, the LPA went into the staff room. At 11:07 a.m., the LPA went into the unlocked staff room and LPA observed two medication bottles accessible. S1 admitted that the medications were theirs; however, the medication was accessible at the time of the visit. Upon observation, S1 locked up the medications. At the time of the visit, the medication cabinet was locked. Based on observation, the allegation ‘failure to keep medications inaccessible’ is Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 07/20/2021
NARRATIVE
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Regarding the allegation: Failure to provide sufficient staff to meet residents needs
It was alleged that at the time of the complaint, there was one (1) staff on duty for four (4) residents. It was allegedly noted during a visit conducted on 3/18/2021 from a collateral agency, a resident was observed to be wandering outdoors unsupervised while other residents were indoors and S2 was in the bathroom for 15 minutes leaving no supervision for the residents. Another visit was conducted by a collateral agency on 5/6/2021, in which the front door was observed open, residents were wandering during that visit.

Interviews with the owner and Administrator confirmed that they have on-call staff to assist as needed, yet the provided schedule did not demonstrate sufficient staffing. Interviews confirmed that S2 no longer worked at the facility but denied observing or receiving complaints about S2’s inability to provide adequate supervision and care. The LPA reviewed the staffing schedule provided to LPA Miller in April 2021. On several days, the LPA observed that there was only one staff on shift for approximately 16 hours in April 2021.

Upon arrival at 10:50 a.m., there was one (1) staff on duty for three (3) residents. The LPA observed S1 in the front yard, and the residents were in the facility. S1 lives at the facility and provides care, R1 and R2 exhibit wandering behavior, and R3 is bedbound. The LPA could not identify documentation as to whether R3 required a two-person assist for care. However, R3 resides in the room that is cleared for bedridden residents. Interviews and observations revealed that the baby gate stationed at one entrance into the kitchen was to prevent residents from wandering into the kitchen. However, the baby gate cannot substitute for sufficient staffing. During today’s visit, the LPA observed that R1 and R2 were ambulating throughout the facility, and R1 had to be redirected on several occasions. Until the arrival of owner Akhtar "Ellie" Roshanaeian, S1 was left alone solely to cook, execute housekeeping services, and provide care to residents in the facility. Based on interview and record review, there is sufficient evidence to support the claim that the facility failed to provide sufficient staffing to meet residents needs. This allegation is deemed Substantiated at this time.

Regarding the allegation: Failure to keep facility safe, sanitary and in good repair


It was alleged that the toilet paper holders in both bathrooms were broken. The LPA observed the common hallway restroom and observed that the toilet paper holder was broken. The toilet paper holder in the master bathroom was in operable condition. At 12:19 p.m., the LPA observed a hole in the wall where an electrical socket presumably once was in the common area. At 12:20 p.m., the LPA went into the common hallway bathroom and observed that the towel rack was taken off the wall. Based on observation, the allegation ‘failure to keep facility safe, sanitary, and in good repair’ is Substantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 07/20/2021
NARRATIVE
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Regarding the allegation: Failure to prevent use of bedrooms as passageways
It was alleged that staff used the master bathroom for personal use, yet the master bedroom is occupied by a resident. Interviews conducted with both staff and residents confirmed that staff used the master bathroom for personal use. The LPA observed that the facility had a common hallway bathroom and it appeared to be functional. During today’s visit, the LPA advised staff to use the common hallway bathroom for personal use. Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to prevent use of bedrooms as passageways. This allegation is deemed Substantiated at this time.

Regarding the allegation: Failure to prevent interference with resident’s access to food
It was alleged that in order to stop residents from going into the kitchen, the facility utilized a baby gate to block entryway into the kitchen. Upon entry into the facility, the LPA observed that the kitchen table was pushed against the entryway into the kitchen. In addition, the LPA observed a baby gate at one entrance into the kitchen. During today’s visit, the LPA observed that R1 and R2 were ambulating in the dining area. Staff were providing the residents with food throughout the visit. Interviews confirmed that the baby gate was up to discourage residents from entering the kitchen, because R1 wandered a lot. Based on the information obtained, the allegation of ‘failure to prevent interference with resident’s access to food’ is Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties assessed. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2021
Section Cited
CCR
87355(e)(1)
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87355(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit the appropriate paperwork to Community Care Licensing for the staff. Staff will not work at the facility until the association is complete.
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Based on observation and record review, the licensee did not comply with the section cited above, as three staff (S1, S2, S3) were not associated to this facility, which poses an immediate health and safety risk to residents in care.

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Type A
07/20/2021
Section Cited
CCR
87705(f)(2)
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87705(f)(2) Care of Persons with Dementia. The following items shall be made inaccessible ... Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances ... cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Chemicals, disinfectants, knives, and medication was locked up during the visit. Plan of Correction met.
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Based on observation, the licensee did not comply with the section cited above, as cleaning supplies, disinfectants, and OTC medication was accessible to residents with dementia, which poses an immediate health and safety risk to residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit an updated staffing schedule. Submit a Statement of Understanding, demonstrating how the facility will maintain adequate staffing to meet the needs of the residents. Submit statement by 7/22/2021.

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Based on observation and record review, the licensee did not comply with the section cited above, as the facility experienced periods of insufficient staffing, which poses an immediate health and safety risk to residents in care.
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Type B
07/23/2021
Section Cited
CCR
87307(a)(2)(C)
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87307(a)(2)(C) Personal Accommodations and Services. The following provisions shall apply: No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Review Regulation 87303. Statement of understand, noting how the staff will comply with regulation. Submit statement by 7/26/2021
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Based on interview, the licensee did not comply with the section cited above, as staff are going into a resident’s bedroom to use the en suite bathroom for personal use, which poses a potential personal rights risk to residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2021
Section Cited
CCR
87307(d)(6)
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87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:

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The Administrator has agreed to do the following:
1. Remove the baby gate and move the table to an appropriate position in the kitchen. Submit proof of completion by 7/23/2021.
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Based on interview and observation, the licensee did not comply with the section cited above, as a baby gate and the kitchen table blocked access for the residents to enter the kitchen, which poses a potential personal rights risk to residents in care.
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Type B
07/23/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:



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The Administrator has agreed to do the following:
1. Walk through the facility and repair the observed items. Submit proof of completion by 7/23/2021.
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Based on observation, the licensee did not comply with the section cited above, as the toilet paper holder and electrical socket were in poor condition at the time of the visit, which poses a potential health and safety risk to residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210408143441

FACILITY NAME:GOLDEN CENTURY ASSISTED LIVING INCFACILITY NUMBER:
195850126
ADMINISTRATOR:HAYRAPETYAN, VIKTORYAFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(818) 416-0506
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 3DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Tsisana "Ana" Mikia and Akhtar "Ellie" RoshanaeianTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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2
3
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9
Failure to maintain minimum required food supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit at 10:50 a.m. The LPA was initially greeted by staff Tsisana "Ana" Mikia. The LPA spoke with owner Akhtar "Ellie" Roshanaeian at 11 a.m. and with Administrator Viktorya Hayrapetyan over the phone at 11:31 a.m. and inform them of the reason for the visit. Owner Akhtar "Ellie" Roshanaeian arrived at approximately 12:45 p.m.

During today’s visit, the LPA conducted a physical plant tour from 11:05 a.m. – 11:15 a.m., and conducted an additional tour with owner Akhtar "Ellie" Roshanaeian at 12:50 p.m. The LPA reviewed facility files at 11:20 a.m., and conducted staff interviews at 11 a.m., 11:31 a.m., and 12:47 p.m., and interviewed one out of three residents at 12:05 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20210408143441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN CENTURY ASSISTED LIVING INC
FACILITY NUMBER: 195850126
VISIT DATE: 07/20/2021
NARRATIVE
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Regarding the allegation: Failure to maintain minimum required food supplies

It was alleged that the facility had an insufficient supply of perishable and nonperishable food. During today’s visit, the LPA conducted a physical plant tour of the kitchen and observed a that the minimum requirement for seven (7) days’ worth of nonperishable food and two (2) days of perishable food was met. The LPA observed two cabinets with nonperishable items in good condition. During an initial virtual visit conducted by LPA Eva Miller on 4/13/2021, the facility was observed to have a sufficient supply of perishable and nonperishable food as required by regulation. Based on observation, there is insufficient evidence to support the claim that the facility failed to maintain minimum required food supplies. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9