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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494040
Report Date: 05/15/2026
Date Signed: 05/15/2026 05:14:25 PM

Document Has Been Signed on 05/15/2026 05:14 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:NU BUILDING BLOCKS II-PRESCHOOLFACILITY NUMBER:
197494040
ADMINISTRATOR/
DIRECTOR:		PATRICIA A. HARDYFACILITY TYPE:
850
ADDRESS:3130 W VERNON AVETELEPHONE:
(323) 477-3407
CITY:LOS ANGELESSTATE: CAZIP CODE:
90008
CAPACITY: 34TOTAL ENROLLED CHILDREN: 4CENSUS: 2DATE:
05/15/2026
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Paige SolomonTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 5/15/26 Licensing Program Analysts (LPAs) Angela Luz and Patsy Plancarte, were greeted by Assistant Director Gabriel Chea. Facility representative Paige Solomon arrived shortly after LPAs arrival. LPAs informed facility representative the reason for the visit is to conduct an unannounced Annual/Required inspection. LPA provided facility representative the Entrance Checklist (LIC 125) and the facility was toured indoors and outdoors for a Health and Safety Inspection. Days and hours of operation are Monday through Friday from 6:00 am until 6:00pm.  The facility has an infant license (197494039) at the neighboring address.Facility representative informed LPAs that Licensee passed away in 2022. Facility representatives informed they submitted documentation for a change of ownership in August 2022. LPAs informed if documentation cannot be located, a new application may be required.
During facility tour, LPAs noted 2 preschool aged children and 2 infant aged children in a preschool room being supervised by 1 preschool staff and 1 infant staff. The facility is not operating within the limits and conditions of the license. The infant staff and infant children moved to the infant room. Facility representative understands that preschool children and infant children cannot co-mingle.

All classrooms were inspected for age-appropriate furnishings, equipment, and adequate storage for children’s belongings. LPAs observed furniture and equipment are in good condition and free of sharp, loose or pointed parts. LPAs observed sufficient toys and play materials in good condition. Forms of discipline used at the facility is redirection and talking with the child. LPAs inspected the napping equipment and observed them to be stored in a healthful manner. Napping sheets are provided and washed twice a week by the facility. Blankets are provided and sent home twice a week by the families. Facility has separate staff and child designated bathrooms. Children's toilets and faucets are in safe and sanitary operating condition. The children can reach their designated sinks, toilets, and supplies.
NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040
VISIT DATE: 05/15/2026
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LPAs observed floors and surfaces were free of debris, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged fire extinguisher that is accessible throughout the facility. All cleaning solutions/poisons are kept on high shelves in the classrooms, inaccessible to children in care. No poisons were observed to be accessible to children during the inspection. LPAs observed the center first aid kit contained bandages, scissors, and hand sanitizer. LPAs reminded facility representative to ensure that the first aid kit is fully stocked and provided a list of items to be included. The isolation area for when a child is sick is the office.

The facility provides AM/PM snacks and lunch. All center provided food items are properly labeled & stored separately from cleaning supplies. Food preparation area is free of debris, hazardous materials, and vermin, and is adequately equipped. Menus are posted at least one week in advance on Brightwheel, dated and available for review. LPAs reminded to have the menus posted at the center. Drinking water is accessible by children in the classrooms via water dispenser. LPAs observed the children’s water bottles are labeled with their name. Solid waste containers have tight-fitting lids and are in good repair.

The outdoor play area is fully fenced and has shade available. All equipment and surfaces are free from hazards.  LPAs observed age-appropriate outdoor toys and materials for the children. The large play structure is securely installed into the ground and the ground surrounding the play structures is sufficiently padded with resilient material that is in good condition for safety. Drinking water is provided in water bottles when children are outside. Per Director, there are no firearms or other weapons on the premises. There are no bodies of water, or free-standing water accessible to children.

All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed the facility roster & personnel report and copies were obtained. LPA observed most required postings in a publicly accessible area. The facility utilizes the Brightwheel App for sign/in out and parent communication. LPA reviewed the sign in/out sheets and noted they were in compliance. Fire/disaster drills are recorded, last drill was on 5/15/26. LPAs reminded to record and perform fire/disaster drills at least every six months.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040
VISIT DATE: 05/15/2026
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LPA reviewed 4 children files and 2 staff files during today's inspection. 4 of 4 children's records were missing Physician's Report (LIC 701) signed and dated by the child's physician. Staff 1 and Staff 2 were missing current pediatric CPR/First aid and Mandated Reporter certification for child care providers. Facility representative was reminded to renew CPR/First aid and Mandated Reporter certifications every 2 years. Staff 1 is missing proof of immunization against measles and pertussis.

Facility representative 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.

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.

LPA referred facility representative 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)
CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE
NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040
VISIT DATE: 05/15/2026
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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/.

Facility representative 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.

LPAs Angela Luz and Patsy Plancarte informed facility representative Paige Solomon that this report dated 5/15/26 documents 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Angela Luz and Patsy Plancarte informed the facility representative to provide a copy of this licensing report dated 5/15/26 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.

4 Type B deficiencies are issued. 1 Advisory Note is issued.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the facility representative Paige Solomon.
NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2026 05:14 PM - It Cannot Be Edited


Created By: Angela Luz On 05/15/2026 at 03:39 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: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101161(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 2 of 2 infant children in the preschool room with preschool children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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By plan of correction due date, facility representative will submit a written plan on how they will keep the infant and preschool components separated throughout the day. The plan shall include coverage for staff breaks.
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.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Angela Luz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


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Document Has Been Signed on 05/15/2026 05:14 PM - It Cannot Be Edited


Created By: Angela Luz On 05/15/2026 at 03:39 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: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

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 1 of 1 water outlets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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By plan of correction due date, facility representative will inform LPAs of scheduled lead testing. By the next business day after the lead testing is completed, facility representative will submit completed LIC 9275, LIC 9276, and LIC 999 at indicated the tested water outlet.
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 2 of 2 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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By plan of correction due date, facility representative will submit current Mandated Reporter certifications for Staff 1 and Staff 2.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Angela Luz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


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Document Has Been Signed on 05/15/2026 05:14 PM - It Cannot Be Edited


Created By: Angela Luz On 05/15/2026 at 03:39 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: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 2 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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2
3
4
By plan of correction due date, facility representative will submit proof of immunization against measules and pertussis for Staff 1.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

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 2 of 2 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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3
4
By plan of correction due date, facility representative will submit current certification for pediatric CPR/First aid for Staff 1 and Staff 2.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Angela Luz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


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Document Has Been Signed on 05/15/2026 05:14 PM - It Cannot Be Edited


Created By: Angela Luz On 05/15/2026 at 03:39 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: NU BUILDING BLOCKS II-PRESCHOOL
FACILITY NUMBER: 197494040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 of 4 children's records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
1
2
3
4
By plan of correction due date, facility representative will submit proof of completed LIC 701 for each enrolled child.
Section Cited
Deficient Practice Statement
1
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.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Angela Luz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


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