197494854-6-19-2026-30-CC-ALUZ-DV7QCA-20260619120250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494854
Report Date: 06/19/2026
Date Signed: 06/19/2026 12:04:32 PM

Document Has Been Signed on 06/19/2026 12:04 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:	ZHOU FAMILY CHILD CARE		FACILITY NUMBER:	197494854
ADMINISTRATOR/ DIRECTOR:	ZHOU, XIN YAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 706-8300
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	06/19/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Xin Yan Zhou		TIME VISIT/ INSPECTION COMPLETED:	12:15 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 6/19/26, Licensing Program Analyst (LPA) Angela Luz met with Licensee Xin Yan Zhou, to conduct an unannounced annual random inspection. Also present at the time of inspection was 9 children (3 infant and 6 preschool age). The facility is operating within the terms of the license. The home was toured to conduct a Health and Safety Inspection. Entrance Checklist for Family Child Care Home was provided and licensee was reminded of documents to be posted in a prominent, publicly accessible area of the facility. Days and hours of operation are Monday to Friday 8AM to 6PM. Ages served are newborn to 5 years old. English and Mandarin are spoken to the children in care. Licensee speaks English and Mandarin. Licensee's preferred language is Mandarin. The home is a 2 bathroom, 3 bedroom, single story, single family home. Licensee toured the on limit areas of the facility with LPA. The home is neat and free of debris with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the front yard, living room, bathroom #1, and family room. The OFF LIMIT AREAS are kitchen, all bedrooms, bathroom #2, backyard, and detached garage. LPA noted child gates in the hallway leading to the bedrooms and bathroom #2, around the kitchen entry, and around the back door that leads to the garage and backyard. The ISOLATION AREA is the living room.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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 15

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 15

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
	VISIT DATE: 06/19/2026

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

Families drop off at the front door or in the living room. The main child care area is the family room. LPA noted ample age-appropriate toys that appear to be safe and in good condition. LPA noted a screened fireplace that is additionally covered with children's storage.

Licensee states they uses talking with the child as a form of discipline. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, intimidation, or other actions of a punitive nature. Licensee understands that children are to be treated with dignity, receive safe, healthful, and comfortable accommodations. LPA reminded that Licensee is required to be present for 80% of operating hours per day. Licensee understands how to report Unusual Incidents/Injuries.

LPA observed 1 play yard. The play yard meets the safety standards. The play yards does not hinder entrance or exit to and from the space where infants are sleeping. The mattresses pads in the play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the play yard.

LPA informed infants in care shall not be swaddled, including sleep sacks. Licensee stated they physically check on sleeping infants and stay next to them while sleeping. Documentation of 15 minute sleep checks that notate any signs of distress were missing. LPA reminded the 15 minute sleep checks are required for infants 0-24 months old. A 10 month old was missing Individual Infant Sleeping Plan (LIC 9227) from their file. LPA reminded that the LIC 9227 is required for children 0-12 months old. Licensee understands Infant Safe Sleep requirements.

The front yard is fully fenced. LPA noted age appropriate outdoor play materials. LPA noted a broken slide. The bottom portion of the slide was cracked and portions of plastic were missing, creating a hole. Licensee stated they will remove the slide.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 3 of 15

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
	VISIT DATE: 06/19/2026

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

There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water.

All hazardous materials and toxins are kept out of the reach of children. Cleaning supplies are kept under the kitchen sink. Licensee understands that any materials that are labeled “Keep out of reach of children” or have similar messaging should be kept out of reach from children in care.

Licensee states that there are no firearms in the home. The home has a fully charged 2A10BC fire extinguisher that was last purchased in 2021, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded that fire extinguishers should be serviced or newly purchased annually.

Licensee Pediatric CPR/First Aid is expired. Licensee has a pediatric CPR/First Aid class scheduled with the Red Cross on 7/25/26. Licensee Mandated Reporter Training for Child Care Providers is current and expires on 4/16/28. Licensee was reminded that Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file.

Licensee stated they conduct fire/disaster drills at least every six months. Licensee stated their last drill was in 2/26 but did not have documentation. Licensee performed earthquake drill during facility visit today and created a log for it. LPA advised the best practice is to conduct and document a fire/disaster drills every month.

A current facility roster was viewed. 3 of 14 children had incomplete information. LPA reminded to ensure each child's information is recorded accurately. Licensee does not have liability insurance. Affidavit Regarding Liability Insurance (LIC 282) were found in children’s files.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 4 of 15

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
	VISIT DATE: 06/19/2026

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 reviewed 6 children files. 6 of 6 files were missing Consent for Emergency Medical Treatment (LIC 627). LPA reminded that children's immunizations need to be transferred to the California Pre-Kindergarten and School Immunization Record and provided a blank copy to Licensee.

Licensee stated they do not have records for their assistant. LPA reviewed required records for assistants. During the visit, assistant completed Employee rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), and flu declination.

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.

LPA 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-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

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.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 5 of 15

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
	VISIT DATE: 06/19/2026

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) 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/.

During the exit interview, the Licensee Xin Yan Zhou, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

5 Type B deficiencies are issued. 6 Advisory Notes are issued.

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

Exit interview conducted and report was reviewed with the licensee Xin Yan Zhou.

NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 6 of 15

Document Has Been Signed on 06/19/2026 12:04 PM - It Cannot Be Edited

Created By: Angela Luz On 06/19/2026 at 11:12 AM

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of a broken slide in the front yard, the licensee did not comply with the section cited above in 1 of 1 slides which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	By plan of correction due date, Licensee will remove the slide in the front yard and send LPA proof.

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
1 2 3 4	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: 07/03/2026
	Plan of Correction
1 2 3 4	By plan of corrections due date, Licensee will submit completed Mandated Reporter Training for Child Care Providers for the assistant.

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: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 7 of 15

Document Has Been Signed on 06/19/2026 12:04 PM - It Cannot Be Edited

Created By: Angela Luz On 06/19/2026 at 11:12 AM

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(d)

Personnel Records

(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. 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 1 of 1 assistants which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2026
	Plan of Correction
1 2 3 4	By plan of correction due date, Licensee will submit a complete personnel record for their assistant.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. 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 6 of 6 children's files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2026
	Plan of Correction
1 2 3 4	By plan of correction due date, Licensee will submit completed Consent for Emergency Treatment (LIC 627) for reviewed children's records.

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: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 8 of 15

Document Has Been Signed on 06/19/2026 12:04 PM - It Cannot Be Edited

Created By: Angela Luz On 06/19/2026 at 11:12 AM

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: ZHOU FAMILY CHILD CARE	FACILITY NUMBER: 197494854
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

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: 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 3 of 3 infants which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2026
	Plan of Correction
1 2 3 4	By plan of correction due date, Licensee will submit proof of 15 minute sleep checks that notate any signs of distress for infants in care. Sleep checks shall include the infant's name, date, time of check, and initials of person who conducted the check.

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: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

Page: 9 of 15