197417299-9-2-2026-58-CC-DFEN-DXJRC3-20260902125339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197417299
Report Date: 09/02/2026
Date Signed: 09/02/2026 12:54:03 PM

Document Has Been Signed on 09/02/2026 12:54 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:	UCLA WESTWOOD CHILD CARE CENTER		FACILITY NUMBER:	197417299
ADMINISTRATOR/ DIRECTOR:	NICOLE FIORELLA		FACILITY TYPE:	830
ADDRESS:	10861 WEYBURN AVENUE #301		TELEPHONE:	(310) 481-0664
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90024
CAPACITY: 63	TOTAL ENROLLED CHILDREN: 54	CENSUS: 44	DATE:	09/02/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:36 AM
MET WITH:	Ann Baires-Assistant Director		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/022026, Licensing Program Analyst (LPA) DeCondia Ferguson conducted an unannounced Annual Random inspection of LPA arrived at the facility at 08:36 am. Upon arrival, LPA met with Assistant Director Ann Baires. The purpose of the inspection was explained and a copy of LIC125 Entrance Checklist – Child Care Centers was provided to help facilitate the inspection. Assistant Director Ann Baires explained the program operations and guided LPA on a tour of the facility. A review of the facility’s compliance with Title 22 regulations and health and safety requirements was conducted. Note: UCLA Westwood Child Care Infant Center (Bright Horizons) located at 10861 Weyburn Ave #301, Los Angeles, CA 90024 is the address for Target as this is where the facility receives their mail. Per Assistant Director the address to use to locate facility is 10850 LeConte Ave., Los Angeles, CA 90024. Facility is located on the roof of the Target and Ralphs shopping center. Access to enter facility parking structure is located on LaConte. The ramp up to the facility is next to the Ralphs parking lot. This is a infant program licensed for 63 infants aged 6 weeks to 24 months. Hours of operation are Monday through Friday from 07:30 am to 05:30 pm. LPA observed all required documents to be posted in a prominent, publicly accessible area at the facility. LPA observed 44 children and 14 teaching staff, 1 cook and 1 Director. LPA observed LIC9040 to reflect 54 children currently enrolled. All children are under supervision, including visual supervision, of a teacher at all times. Capacity and limitations as specified on the license are being maintained in accordance with Title 22 regulations. A walk through of the classroom and outside areas was conducted. All areas identified on the Facility Sketch were inspected. LPA observed 3 licensed infant classrooms and 3 licensed toddler classrooms on the premises.

Raul Navarro
Decondia Ferguson
	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

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)

Page: 2 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

RM A1 - Infant: 5 children with a ratio of 2 teachers; RM A2 - Toddler: 10 children with a ratio of 3 teachers; RM L1 - Toddler: 9 children with a ratio of 2 teachers; RM L2 - Infant: 6 children with a ratio of 2 teachers; RM L3 - Infant: 6 children with a ratio of 3 teachers; RM L4 - Toddler: 8 children with a ratio of 2 teachers

Classrooms were observed to be clean, well-organized, and free of potential hazards. Furniture was in good repair and equipped with age-appropriate furniture, toys, and materials.

LPA observed the infant sleeping area to be physically separate from the indoor activity space. LPA observed cribs and sleeping equipment to be in safe condition and appropriately arranged to allow staff access and visibility of infants. Cribs were equipped with firm, properly fitted mattresses covered with moisture-resistant material and tight-fitting sheets. Cribs were observed to be free of loose articles, including blankets, pillows, toys, bumper pads, and other objects that could pose a potential safety hazard. No objects were observed hanging above or attached to the sides of the cribs. Sleeping equipment was arranged so as not to obstruct entrances or exits and to allow staff access to each infant without stepping or reaching over another infant. LPA observed appropriate sleeping equipment available for infants based on their developmental needs, including mats or cots for infants able to climb out of a crib. LPA also reviewed the facility's Individual Infant Sleeping Plans (LIC 9227), as applicable. Infant sleeping equipment and the sleeping area were observed to be in compliance with Title 22 requirements.

Trash cans in all classrooms had tight-fitting lids, and all cleaning supplies, disinfectants, and other hazardous materials were stored securely in locked cabinets, inaccessible to children. All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free.

Telephone service, heating, lighting and ventilation were evaluated and found to be adequate.

Children’s belongings are stored in cubbies in each classroom. Parents provide blankets for each child which are taken home weekly on Fridays for laundering. The program maintains additional linens on site for use in the event of accidents or as needed. Per Assistant Director cribs sheets are washed daily. In the event children become ill the designated isolation area is located in the lobby.
Page 2

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 3 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

First Aid supplies were observed and in all 6 rooms and were well stocked. Per Assistant Director, Incidental Medical Services are provided. LPA observed medication stored in individual bags for children labeled with their names. Medications labels were checked for expiration dates, medical instructions, and correct documentation for each child, all in compliance. Per Assistant Director there are no children who require refrigerated medication.

LPA observed tamper-resistant electrical outlets installed throughout the facility. The facility is equipped with operational smoke and carbon monoxide detectors, in compliance with Title 22, Section 101238(b). 5 Fire extinguishers (2A:10BC) were observed throughout the facility with a current service date of 04/07/2026 in accordance with Title 22, Section 101238(b)(1). LPA observed well stocked First Aid kits in all 6 classrooms to be complete in accordance with Title 22, Section 101226. The fire drill log was reviewed and found to be current in accordance with Title 22, Section 101237. Last drill was conducted 08/14/2026.

LPA observed that toilets are not currently utilized by children enrolled in the infant/toddler program. Assistant Director reported that children do not begin toilet training until transitioning to the two-year-old classroom. Assistant Director further reported that toddlers who are not toilet trained utilize disposable pull-ups, which are changed as needed in the designated diaper-changing area. LPA observed a separate staff restroom is available and inaccessible to children in care.

Cleaning compounds, medications, and other hazardous items were observed to be inaccessible to children in accordance with Title 22, Section 101238(a). No poisons were observed in the classrooms.

Kitchen, food preparation, and food storage areas were observed to be clean and maintained in a sanitary condition in accordance with Title 22, Section 101227 (Food Service). Refrigerators maintain safe temperatures, and cleaning agents, detergents, and other hazardous substances are securely stored separately from food supplies. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Solid waste containers were observed to have tight-fitting covers and be in good repair. LPA observed the kitchen is inaccessible to children. Per the Assistant Director, the facility provides snack daily with snack menu posted monthly. LPA observed dietary restrictions/allergy forms. Form is located in each classroom along with kitchen/cook maintaining a copy. LPA observed a menu posted in each classroom. Page 3

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 4 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed drinking water to be readily available indoors and outdoors. Water is available to children through personal sippy cups and paper cups. Water bottles are refilled through water pitcher filled by filtered water system brought to each classroom by the cook.

The infant center has 1 outdoor play area, all fully enclosed and fenced. Outdoor play equipment was observed to be maintained in a safe condition and free of hazards/debris. Per Assistant Director, buildings and grounds for UCLA clean the yard daily. There is adequate shade in the play yard. LPA advised that no children shall be left without the supervision of a teacher at any time.

The program uses an electronic sign-in/out system, My Bright Day along with paper sign-in/out. Children were properly documented during the inspection.

Children’s records were reviewed for Admission Agreement, LIC613 Personal Rights, LIC700 Identification and Emergency Information, LIC 701Physicians Report, LIC702 Children’s Preadmission Health History, LIC995 Notification of Parents’ Rights, LIC627 Consent for Medical Treatment, LIC9227 Infants Needs and Service Plan, Sleep Log, and Immunization Records. Children’s records were reviewed and found to be complete.

Staff records were reviewed for Education, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC501: Personnel Record, LIC503 Health Screening, LIC508 Criminal Record Statement, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, current Mandated Reporter Training Certificate and LIC9052 Employee Rights, There is at least one person trained in CPR and Pediatric First Aid and at least one person with Preventative Health, Safety, Nutrition and Lead training valid during this inspection. All staff present had current criminal record clearances on file.

Assistant Director was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. LPA discussed the Community Care Licensing website www.ccld.ca.gov which provides access to resources such as forms, regulations, Provider Information Notices (PINS), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 101212).

Page 4

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Assistant Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified. Regulation prohibits the smoking of tobacco on the premises. Assistant Director states there is no smoking in the facility.

The following were also discussed with the Assistant Director:

Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. All appeals must be sent to: California Department of Social Services, Community Care Licensing, 300 Continental Blvd., #290A, El Segundo, CA 90245

Assembly Bill 1207: California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com.

Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each child care center or family child care home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program or an accredited college or university.

Page 5

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Criminal Record Clearance: Assistant Director Ann Baires was reminded that all adults 18 and over, 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 Child Care Center. 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.

Lead Testing: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test as specified in Health and Safety Code section 1597.16.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP.).

LPA verified that the lead testing was completed in accordance to the Written Directives (Interim Licensing Standards) outlined in PIN 21-21.1-CCP. Child Care Center completed testing November 29, 2022 and no Lead Exceedances.

LPA referred Assistant Director Ann Baires to the Department website for lead: Lead Toxicity Prevention and Water Testing Information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information)

Safe Sleep: LPA discussed the safe sleep regulations with Assistant Director Ann Baires and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Assistant Director Ann Baires of the importance of checking for and removing any 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.

Page 6

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: UCLA WESTWOOD CHILD CARE CENTER	FACILITY NUMBER: 197417299
	VISIT DATE: 09/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Incidental Medical Services (IMS): This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

MyChildCarePlan.org: Assistant Director Ann Baires 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.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Assistant Director Ann Baires

Page 7

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC809 (FAS) - (06/04)

Page: 8 of 8