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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494863
Report Date: 06/30/2026
Date Signed: 06/30/2026 12:28:36 PM

Document Has Been Signed on 06/30/2026 12:28 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:HAGGERSTROM FAMILY CHILD CAREFACILITY NUMBER:
197494863
ADMINISTRATOR/
DIRECTOR:		CECILIA HAGGERSTROMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 633-3375
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
06/30/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Cecilia HaggerstromTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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 06/30/2026 Program Analyst (LPA) Judy Laureano conducted an unannounced Annual/Random Inspection at above mentioned facility. LPA was greeted by licensee Cecilia Haggerstrom.

LPA toured the inside and outside of the home and observed 6 children with 2 assistants providing care and supervision. LPA confirmed via Guardian roster that all individuals present in the home have a clear criminal record clearance.

Facility operates Monday through Friday from 8:00 a.m. to 5:00 p.m. Currently licensee is available to care for children 6 months to 3 years old. Facility is Large Family Child Care Home with a max capacity of 14.

Current facility sketch reviewed and Licensee confirmed that bedroom 2, playroom and bathroom are used for day care. Back yard is used as an outdoor space.

The following areas are confirmed as OFF LIMITS: Bedroom 1, Bedroom 3, Bedroom 4, bathroom 1 and bathroom 2, living room, dining room, kitchen and detached garage.

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. Detergents and cleaning compounds are kept away from the children, under the sink cabinet in the kitchen.

All electrical outlets were observed to be covered. LPA reminded licensee to ensure all areas that have been designated as OFF LIMITS need to have doors closed when children are present.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2026
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 06/30/2026
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Families access the day care through main entrance of the home. Upon entry, LPA entered the living room area, designated as OFF LIMITS. A barricaded fireplace was observed in the living room space. Next to the living room, a safety gate was observed that leads to the playroom, designated as day care space. LPA observed age-appropriate toys and materials for children to use.

A small hallway was observed that leads to the bedroom and bathroom that children use. 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.

Kitchen was observed and inspected; area has been designated as OFF LIMITS. Families are responsible for providing 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.

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

Licensee confirmed that home does not to take in children that need incidental medical services.

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

License confirmed that fire drills and earthquake drills are completed. Per licensee, drills are completed but not documented, Type B citation was issued. Each family childcare 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 be kept at the family child care home.

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

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 06/30/2026
NARRATIVE
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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.

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. 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. Per licensee, Sleep checks are being documented on a whiteboard only, Type B citation issued.

Capacity as specified on the license is being maintained during today’s inspection.

Proof of Pediatric CPR and Pediatric First Aid was observed for Licensee and assistant. Licensee’s current Pediatric CPR and Pediatric First Aid was taken on 11/16/2024. Mandated Reporter Training Certificate was not available for review for Licensee and Assistant M. Sanchez, Type B citation issued. Documentation of immunization record for MMR and Dtap for Assistants, M. Sanchez and P. Tejeda, was not available for review, Type B citation issued. 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.

LPA reviewed 4 children’s file and observed files to be incomplete with 2 out of 4 files missing proof of immunization, Type B citation issued. Three out of 4 children’s file were missing a completed LIC 627 Consent for Emergency Medical Treatment, Type B citation issued.

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

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 06/30/2026
NARRATIVE
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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-andresources/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.

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.

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 with Appeal Rights were reviewed with the licensee Cecilia Haggerstrom.
NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 06/30/2026 12:28 PM - It Cannot Be Edited


Created By: Judy Laureano On 06/30/2026 at 10:53 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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in documenting drills completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Licensee will create and log that will be used to documents disaster drills completed. Licensee will email document to LPA by POC due date.

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: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2026 12:28 PM - It Cannot Be Edited


Created By: Judy Laureano On 06/30/2026 at 10:53 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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

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 training certificate for 2 out of 3 files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Licensee agrees to submit proof of completed Mandated Reporter Training for Licensee and Assistant M. Sanchez via email by POC due date.
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 2 out of 3 files did not have proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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LIcensee agrees to submit proof of immunization record of MMR, Dtap to LPA via email for Licensee and two assistants.
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: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2026 12:28 PM - It Cannot Be Edited


Created By: Judy Laureano On 06/30/2026 at 10:53 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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 children's file that need proof of immunization record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Licensee agrees to collect copies of immunization records for two children; C. Black and L. Deleon.
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
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Based on record review, the licensee did not comply with the section cited above in 3 out 4 children's file did not have a completed LIC 627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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3
4
Licensee agrees to collect completed LIC 627 for 3 out of 4 children's file and submit proof via email to LPA.
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: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 06/30/2026 12:28 PM - It Cannot Be Edited


Created By: Judy Laureano On 06/30/2026 at 10:53 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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

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 interview and record review, the licensee did not comply with the section cited above in maintaining documentation of the 15 min Sleep Log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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2
3
4
Licensee agrees to creat a Sleep Log that will be completed and maintained in the children's file.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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