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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403978
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:04:38 PM

Document Has Been Signed on 08/19/2025 04:04 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GHAFARI-MOBARHANI FAMILY CHILD CAREFACILITY NUMBER:
197403978
ADMINISTRATOR/
DIRECTOR:		MARYAM GHAFARI-MOBARHANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 487-1023
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
08/19/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Maryam Ghafari MobarhaniTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 08/19/2025 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual 3 year Required Inspection at above mentioned facility. LPA was greeted by Licensee Maryam Ghafari-Mobarhani who lead LPA on a tour of the home.

LPA observed 6 children present during today’s inspection.

Based on documents reviewed and observation, licensee had a total of 5 infants present during today's inspection 08/19/2025. LPA verified dates of birth of all children present today. Licensee was informed that she must come into capacity during the course of the inspection. LPA cited 1 deficiency cited during today’s visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1.

The hours of operations are Monday to Friday open 8:00 a.m. to 5:00 p.m. License confirmed homes care for children ages 6 months to 5 years old. Facility is licensed for a Large Family Child Care license with a max capacity of 12 children.

The home is located in a multi unit lot. Home was observed with 2 bedrooms, 1 bathroom, living room, dining room and kitchen area. An enclosed back yard was observed and inspected.

Licensee confirmed bedroom 2 is OFF LIMITS to the children in care and door remains locked during the hours of operations and/or while children are present.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978
VISIT DATE: 08/19/2025
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As on you enter the home you are led to the living room area, designated as day care space. LPA observed age-appropriate materials such as toys, puzzles and a variety of soft toys. LPA observed children’s size table and chairs. Licensee confirmed that children nap in the living room. LPA observed a barricaded open face heater in the living room space. Parent board was observed in the living room area. LPA provided licensee with the most up to date posting to ensure Licensee is displaying the most current information.

Dining room area was observed with soft toys and a changing table station.

A small hallway was observed that leads to bedroom 1 and bedroom 2. Bedroom 1, closest to the living room space has been designated a day care space; area was observed and inspected.

Bathroom that children use is located down the small hallway. LPA observed and inspected the toilet, sink and bathroom area. LPA reminded licensee to ensure all toiletries are made inaccessible to the children in care and/or while children are present.

The licensee was informed that any changes to ages, hours and days of operation shall be submitted to the department via signed LIC 279, for approval prior to initiation of changes.

Kitchen was observed and inspected. Knives and sharp objects were observed inaccessible to the children in care. LPA observed one safety gates between the dining room and kitchen, making the kitchen inaccessible to the children in care.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection.

Licensee confirmed that home is open to take in children that need incidental medical services. LPA discussed incidental medical services with Licensee. Prescription medications shall be administered in accordance with the label directions as prescribed by the child’s physician. Medication should be in its original content with current prescription with all necessary LIC forms completed.

LPA observed licensee test the smoke detector and carbon monoxide in the home. A working fire extinguisher was observed in the daycare space. LPA reminded licensee that fire extinguishers need to be service annually and proof of such service needs to be available for LPA’s review.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978
VISIT DATE: 08/19/2025
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Licensee confirmed that fire drills and earthquake drills are completed at the home. LPA recommended Licensee to add additional information such as number of children and time drill was completed. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

Licensee stated families are required and provide all meals and snacks. LPA discussed the importance of maintaining a system where allergies and food restrictions are noted. LPA encouraged licensee to contact their local resource and referral agency, Connections for Children, to inquire about the different resources and professional development opportunities available.

Adequate heating and ventilation for safety and comfort were observed in the space. The home has a working telephone service and LPA confirmed the phone number and email address.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles.

Safe Sleep regulations were discussed due to program being available for infant care. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Infants up to 12 months of age are placed on their backs for sleeping. LPA discussed the importance of maintaining a current sleep log for all children under the age of 24 months. Safe Sleep log was not available for review, Type B citation was issued. Licensee agrees to create a sleep log for all children under the age of 24 months and send copy to LPA via email.

Licensee’s Pediatric CPR and Pediatric First Aid was reviewed and observed with an expiration date of Mandated Reporter Training was taken 03/2026. Proof of immunization, MMR and Tdap was not available for reviewed, Type B citation was issued.

Mandated Reporter Training was not available for review; Type B citation was issued.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978
VISIT DATE: 08/19/2025
NARRATIVE
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LPA discussed the importance of creating a file for licensee that includes all the necessary LIC documents, including but not limited to, First Aid and CPR, Mandated Reporter Training, Immunizations- MMR and tdap, TB clearance, and Flu Vaccine and/or waiver.

LPA reviewed 6 children’s file and observed files complete with all the necessary CCL forms.

LPA provided licensee with current forms for children’s records. LPA discussed all necessary forms needed in each staff file and children’s file. LPA provided licensee with a current copy of the LIC 311D and LIC 126 to use as a reference when auditing files; documents were provided during today’s inspection.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.


Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978
VISIT DATE: 08/19/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations and Health and Safety Code, A type A deficiency is cited.

LPA Judy Laureano informed licensee Maryam Ghafari-Mobarhani that this report dated 08/19/2025 documents 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Laureano informed the licensee Maryam Ghafari-Mobarhani to provide a copy of this licensing report dated 08/19/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will results in a civil penalty of 100.00.

An exit interview was conducted, and a copy of this report and appeals rights was provided to Licensee Maryam Ghafari-Mobarhani.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/19/2025 04:04 PM - It Cannot Be Edited


Created By: Judy Laureano On 08/19/2025 at 01:17 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: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

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 having 5 children under the age of 24 months in care during today's inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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By the end of the inspections, Licensee was in compliance with 3 infants present. Licensee agrees to review CCLD Child Care video- How many children can attend a family child care? and send statement of understanding to LPA via email.
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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Judy Laureano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2025 04:04 PM - It Cannot Be Edited


Created By: Judy Laureano On 08/19/2025 at 01:17 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: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

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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Based on record review, the licensee did not comply with the section cited above in having proof of Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2025
Plan of Correction
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Licensee agrees to complete Mandated Reporting Training and submit proof of completion via email by 9/2/2025.
https://mandatedreporterca.com/training/child-care-providers
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(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
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Based on record review, the licensee did not comply with the section cited above in proof of MMR and Dtap/ Tdap on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2025
Plan of Correction
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2
3
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Licensee agrees to submitt proof of immunization record (MMR and Dtap/Tdap) via email to LPA by POC due date of 9/2/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Judy Laureano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2025 04:04 PM - It Cannot Be Edited


Created By: Judy Laureano On 08/19/2025 at 01:17 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: GHAFARI-MOBARHANI FAMILY CHILD CARE
FACILITY NUMBER: 197403978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and Licensee's interview, the licensee did not comply with the section cited above in having a Sleeping Log for all infants in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2025
Plan of Correction
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2
3
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Licensee agrees to submitt copy of Sleeping log for all children under the age of 24 months via email by POC due date of 9/2/2025.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Judy Laureano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


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