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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850162
Report Date: 12/10/2021
Date Signed: 12/10/2021 05:16:37 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
11/23/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20211123163312
FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cezar Tolentino, DesigneeTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility has insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegation. The LPA met with Designee Cezar Tolentino at 1:40 p.m., and explained the reason for the visit.

During today’s visit, the LPA conducted a physical plant tour at 1:48 p.m., to ensure there are no health and safety hazards. From 2:10 p.m. until 2:17 p.m., the LPA conducted an interview with one (1) residents. From 2:19 p.m. until 2:31 p.m., the LPA conducted an interview with resident family member.


Continue on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 12/10/2021
NARRATIVE
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On 12/2/2021, LPAs Salia Walker and Elsie Campos conducted an unannounced initial 10-day complaint inspection for the above allegations. During the visit, the LPAs conducted a physical plant tour at 1:39 p.m. to ensure there are no health and safety hazards. From 2:09 p.m. until 2:34 p.m., the LPAs conducted interviews with two (2) staff. From 2:38 p.m. until 3:03 p.m., the LPAs conducted interviews with three (3) out of four (4) residents. From 3:03 p.m. until 3:40 p.m., the LPAs reviewed and obtained copies of documents pertinent to the investigation. The LPAs determined, at that time, that further investigation was required.

Regarding the allegation, ‘Facility has insufficient staffing,’ the complainant’s concern is that staff often have to work alone at the facility around the clock. As a result, the complainant is concerned that resident’s needs are not being met.

During the investigation, LPAs Walker and Campos conducted interviews with facility residents, staff, the administrator, and resident family member. Interviews revealed that ‘staff is available around the clock’, ‘alternating between each other’, and that there is ‘usually two (2) if not more staff.’ The LPAs observed that there were two staff working on 12/2/2021. The staff did not indicate that they were left alone to provide resident care or that the work was too demanding for the two staff. The resident’s hygiene needs appeared to have been met as everyone was well dressed and groomed. There were no facility odors and the physical plant of the facility was clean, sanitary and in good repair. There were no resident complaints of needs not being met. There was evidence in early November 2021 that the facility had insufficient staffing and they were cited for this on November 8, 2021; however, currently, they appear to be appropriately staffed.

Based on interviews with residents, staff, and the administrator, there is insufficient evidence to support the allegation ‘Facility has insufficient staffing.’ Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
11/23/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20211123163312

FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cezar Tolentino, DesigneeTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Facility staff are not qualified to care for residents

Facility has insufficient food supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation findings for the above allegations. The LPA met with Designee Cezar Tolentino at 1:40 p.m., and explained the reason for the visit.

On 12/2/2021, LPAs Salia Walker and Elsie Campos conducted an unannounced initial 10-day complaint inspection for the above allegations. During the visit, the LPAs conducted a physical plant tour at 1:39 p.m. to ensure there are no health and safety hazards and to review the food supply. From 2:09 p.m. until 2:34 p.m., the LPAs conducted interviews with two (2) staff. From 2:38 p.m. until 3:03 p.m., the LPAs conducted interviews with three (3) out of four (4) residents. From 3:03 p.m. until 3:40 p.m., the LPAs reviewed and obtained copies of documents pertinent to the investigation. The LPAs determined, at that time, that further investigation was required.
Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 12/10/2021
NARRATIVE
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Regarding the allegation, ‘Facility staff are not qualified to care for residents’, the complainant’s concern is that there is no training given to staff upon employment, and no explanation pertaining to specific residents' needs; staff just have to try to figure it out as they go.

During the investigation, LPAs Walker and Campos conducted interviews with facility staff, residents, and the administrator. Staff interviews revealed that no training was received upon employment. The LPAs also attempted to conduct a record review of staff files, but were unable to do so, as there were no staff files at the facility. The LPAs requested that the administrator provide a copy of the staff files, which included all staff training, to the LPA during the 12/2/21 visit. As of today, copies of the staff files and staffing training has not been provided to the LPA. There is no evidence to conclude that the staff have received the specifically required ten (10) hours of initial training within the first four weeks of employment, the four hours of training annually thereafter; or the required on the job training in the six (6) identified areas listed under section 87411 (d)(1-6) Personnel Requirements – General. In addition, there was no evidence that the facility staff received the required medication training or ‘Care of Persons with Dementia’ training.

Based on the record review, interviews with staff, residents, and the administrator, there is sufficient evidence that upon hire, staff have not received the required training and as a result, ‘Facility staff are not qualified to care for residents.’ Therefore, this allegation is deemed Substantiated at this time.

Regarding the allegation, ‘Facility has insufficient food supplies,’ the complainant’s concern is that there is often no food at the facility. As a result, there is concern that residents are not provided the necessary quantity and variety of food to meet the recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.

During the investigation, LPAs Walker and Campos conducted a physical plant tour, and conducted interviews with facility staff, and residents. During the physical plant tour on 12/2/21, the LPAs did not observe an adequate supply of nonperishable foods for a minimum of one week or an adequate supply of perishable foods for a minimum of two (2) days.

Continue on LIC9099C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 12/10/2021
NARRATIVE
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During the review, the LPAs observed six (6) cans of Pork and Beans, which contains 3.5 servings per can, six (6) cans of kidney beans, which contains 3.5 servings per can, and two (2) medium sized cans of Sun Vista pinto beans which contains 3.5 servings per can and four (4) cans total of various types of Vienna sausage, with approximately 2 servings per can. There were approximately four (4) cans of Chunky Chicken Noodle soup, which contains two (2) servings per can. There were four (4) cans of tomato sauce and there were ten (10) cans of tomato soup concentrate; however, the facility had no bottles of water available to add to the concentrate at the time, should the soup be needed during an emergency and the facility water was shut off. There was no evidence of any canned fruit or a variety of canned vegetables to help provide a balanced diet as required per the ‘Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. Regarding the perishable food supply, there was a sufficient supply of frozen meat; however, the fresh vegetables red bell peppers, and roman tomatoes were moldy and had to be discarded and there were no frozen vegetables, no fresh fruit or frozen fruit during the initial visit. The facility had a census of four (4) residents on 12/2/2021 and two (2) staff; therefore, there should be a minimum of two cans of vegetables for lunch and two cans of vegetables for dinner per day, which is four cans of vegetables per day times seven (7) days, which would equal twenty-eight (28) cans of vegetables minimum. There should also be two cans of fruit for breakfast, for lunch and for dinner, which equals six (6) cans per day times seven (7) days, equals forty-two (42) cans of fruit; and, there is currently only four cans of Vienna sausage, which would only serve 1.2 meals of protein. The facility should have a protein source available, whether it be canned tuna, salmon, corned beef, chicken, etc. so there is a variety of protein; and, there should be enough for at least two meals per day times seven (7) days. Most facilities cook their meals with fresh/frozen food and the seven (7) day canned food is only rotated into the menu prior to expiration date and replaced immediately so that there is always a sufficient amount of non-perishable food on the premises in the event of an emergency where the facility may not have gas, water or electricity.
Staff interviews revealed that a grocery list is given to the administrator of what is needed for the facility, and someone delivers the groceries. According to staff, deliveries are made ‘about every two (2) weeks and more frequent if anything is needed.’ It must be expressed that the facility is required to maintain on a daily basis, two (2) days-worth of perishable food and seven (7) days-worth of non-perishable food on a daily basis, not once every two (2) weeks. The LPAs interviewed the facility residents regarding their meals. Interview with residents revealed that resident ‘usually buy their own snacks,’ and ‘staff share their snacks.’

Continue on LIC9099C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
VISIT DATE: 12/10/2021
NARRATIVE
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Based on the review of the food accessible in the facility and the servings sizes notated on the cans, the facility only had 3 days-worth of non-perishable food items, though it lacked a balanced diet as there were no canned fruits and only two meals worth of canned meat (protein); and, the facility lacked a balanced diet of the required two-day perishable food supply, as there was only frozen meat available.

During today’s visit, the LPA conducted a physical plant tour at 1:48 p.m., to ensure there are no health and safety hazards. From 2:10 p.m. until 2:17 p.m., the LPA conducted an interview with one (1) residents. From 2:19 p.m. until 2:31 p.m., the LPA conducted an interview with resident family member.
At 1:53 p.m., the LPA observed the facility did not contain an adequate supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. The LPA also did not observe any snacks for residents in care. The LPA advised the Designee, the facility residents are to have in-between meal snacks, unless stated otherwise by a physician. The Designee acknowledged understanding, and stated the administrator will be given an additional list of items to purchase for the facility which will include snacks. At approximately 1:50 p.m., the LPA spoke with Administrator Naira through the Designee’s telephone, to advise that the facility has insufficient food supplies. The Administrator stated she is ‘at work, and will goto the grocery store once [she’s] off.’ Record review revealed, that the facility has been previously cited for the same violation section 87555(b)(26) on 11/8/2021. Therefore, civil penalties will be assessed today for a Repeat Violation.

Based on LPA’s observations, and interviews with staff, and residents, there is sufficient evidence to support the allegation ‘Facility has insufficient food supplies.’ Therefore, this allegation is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
87411(c)
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87411(c) Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit copies of staff training, indicating the completion of madated hour to CCL by 12/13/2021.
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Based on interviews, and record review, the licensee did not comply with the section cited above, as S2 did not receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter, which poses a potential health and safety risk to persons in care.
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Type B
12/13/2021
Section Cited
CCR
87411(d)(3)
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87411(d)(3) Personnel Requirements-General(d)All personnel shall be given on the job training or have related experience..(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit copies of staff training, indicating the completion of madated staff training to CCL by 12/13/2021. 2. Submit a Plan of Action on steps the facility will be taking to ensure all staff will be adequately trained upon employement, per section 87411(d)(3).
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Based on interviews, and record review, the licensee did not comply with the section cited above, as S2 did not receive on the job training to obtain skill and knowledge required to provide necessary resident care and supervision, 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2021
Section Cited
CCR
87555(b)(26)
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87555(b)(26) General Food Service Requirements (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.
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit a receipt showing the purches of perishable and non-perishable food, including sncaks.
2. Submit a copy of the facility's Menu reflecting a months worth of meals. Including breakfast, lunch, and dinner.
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Based on observation, the licensee did not comply with the section cited above, as there was an insufficient amount of both the one-week non-perishable food supply and the two-day perishable food supply, which poses 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20211123163312
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: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2021
Section Cited
CCR
87555(b)(5)
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87555(b)(5)General Food Service Requirements(b)The following food service requirements shall apply:(5)Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious.. and food habits of residents.
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit a receipt showing the purches of perishable and non-perishable food, including sncaks.
2. Submit a copy of the facility's Menu reflecting a months worth of meals. Including breakfast, lunch, and dinner.
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Based on observation, the licensee did not comply with the section cited above, as there were no fresh vegetables, no frozen vegetables, no fresh fruit, frozen fruit or canned fruit in the facility. The only canned vegetables were beans. This poses a potential health and safety risk to persons in care.
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Type B
12/11/2021
Section Cited
CCR
87555(b)(3)
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87555(b)(3)General Food Service Requirements(b)The following food service requirements shall apply:(3)Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician.
This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit a receipt showing the purches of perishable and non-perishable food, including sncaks.
2. Submit a copy of the facility's Menu reflecting a months worth of meals. Including breakfast, lunch, and dinner.
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Based on observation, the licensee did not comply with the section cited above, as there were no snacks in the facilityavailable for all residents. This 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9