197495123-6-30-2026-58-CC-DFEN-DV6TBR-20260618143535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495123
Report Date: 06/18/2026
Date Signed: 06/30/2026 02:21:39 PM

Document Has Been Signed on 06/30/2026 02:21 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:	AZOSE FAMILY CHILD CARE		FACILITY NUMBER:	197495123
ADMINISTRATOR/ DIRECTOR:	MELISSA AZOSE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 369-6709
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS:	DATE:	06/18/2026
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:43 AM
MET WITH:	MELISSA AZOSE		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 06/18/2026 at 11:43 a.m., Licensing Program Analyst (LPA) DeCondia Ferguson conducted an Unannounced Required 3-Year inspection at Azose Family Child Care. Upon arrival, LPA met with Licensee Melissa Azose. LPA discussed the purpose of the visit. The LIC126 Entrance Checklist was provided to help facilitate the inspection. The Licensee guided LPA on a tour of the home inside and out. Days and hours of operation are 08:00am to 04:00pm Monday through Friday. During today’s inspection, LPA observed child care being provided outdoors. During today’s visit a census was taken. LPA observed a total of 12 children present being supervised by Licensee, Licensee Assistant Alida Lopez, and Licensee’s 16-year-old daughter Ava Azose. Licensee states there are 12 children enrolled. Facility was observed to be operating within the conditions, limitations, and capacity specified on the license. During the outdoor inspection, LPA observed a garage converted into a dance studio for Licensee’s own children. Garage was converted last year. Licensee states she does use for the child care but for only 30 minutes at a time in the summer or when it rains. Licensee states she contacted the Department regarding this and was advised 30 minutes or less was okay and to put on a child lock knob and to not allow children to nap in that area. Licensee asked if she could rent the dance space out to dance instructors to supplement her income. LPA advised more information regarding this would be obtained and would provide Licensee with information at a later date.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

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 9

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 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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

A walk through of the home was conducted. All rooms on the facility sketch remain as submitted to the Department with on limit and off-limit rooms clearly identified: 1 bedroom, living room, dining room, kitchen is off limits. On limit room 1 bedroom and two bathrooms. The activity space was found to be clean and free from any potential hazards.

Per Licensee there is napping at the home. Parents provide bedding at the beginning of the year and Licensee washes on Thursdays of each week. Per licensee, in the event children become ill the designated isolation area is in the living room in the home until parents arrive. Per Licensee Incidental Medical Services (IMS) are not offered.

Furniture was in good repair and equipped with age-appropriate furniture, toys, and materials. All cleaning compounds, medications, and other hazardous items were observed to be inaccessible to children. No poisons were observed in the area occupied by children or bathrooms. All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free.

The bathroom and toileting area were inspected. Toilet and sink are properly maintained; toilet and sinks are reachable by the children in care. The bathrooms were found to be clean. There is adequate lighting/ventilation in the bathroom area. Cleaning agents, detergents, and other hazardous substances are securely stored separately using cabinets with safety latches. Solid waste containers were observed to have tight-fitting covers and be in good repair.

Telephone service, heating, lighting and ventilation were evaluated and found to be adequate. Per Licensee there is no smoking on the premises. No registered sex offenders. No firearms in the home. No pools or bodies of water were observed on the premises.

LPA observed tamper-resistant electrical outlets installed throughout the home. The home is equipped with operational smoke and carbon monoxide detectors, tested during the inspection. Fire extinguisher (2A:10BC) was observed. Fire Extinguisher inspection took place on 11/04/2025 per inspection tag. Requirements for disaster drills and documentation for both were reviewed. Last Fire Drill conducted 04/23/2026.

Page 2

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 06/30/2026 02:21 PM - It Cannot Be Edited

Created By: Decondia Ferguson On 06/18/2026 at 01:59 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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.3

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the detached garage is being utilized for care which was previously incdicated as off limits 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	Licensee acknowledged that the garage area designated as off-limits is being utilized for care activities 30 minutes per day without prior notification to the Department. Licensee states she will cease the use of the garage effectively immediately. Licensee will notify the Department before making any future changes to the use of the facility space and will obtain approval as required.

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.

	Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:

	Decondia Ferguson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 4 of 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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

The First Aid kit was complete and is located in the kitchen area. At least one person was observed to be trained in CPR and Pediatric 1st Aid.

The outdoor play area was inspected, all fully enclosed and fenced. Outdoor play equipment was observed to be maintained in a safe condition and free of hazards. The outdoor activity surface was observed to be safe and free of debris. Required cushioning material was present beneath and around climbing structures to absorb falls. 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.

Food preparation and storage areas were observed to be clean and maintained in a sanitary condition. Per Licensee, she provides breakfast, lunch, and one snack daily. The refrigerator was observed to maintain safe temperatures. Cleaning agents and other hazardous substances were stored separately from food supplies. The kitchen is off limits to children. Per licensee there are no children who are allergic to food or require the use of an EPI Pen.

Drinking water was observed to be readily available indoors and outdoors. Water is available to children through a personal water bottle and is refilled as needed.

Children’s records were reviewed for LIC 282 Affidavit Regarding Liability Insurance, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and Immunization Records and were found to be complete.

Licensee has Liability Insurance on file.

Staff records were reviewed for LIC 508-Criminal Record Statement, LIC 9052-Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108-Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. All required immunizations were documented. There is at least one person trained in CPR and Pediatric First Aid and at least one person with one hour of training in the importance of childhood nutrition during this inspection. All staff present had current criminal record clearances on file.

Page 3

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 5 of 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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

During today's inspection a Type B Citation was issued for CCR 102416.3
Alterations to Existing Buildings or Grounds (a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

LPA discussed criminal record clearance requirements with the Licensee and advised that all adults who are employed, reside in, or provide services in a licensed child care facility and have contact with children must obtain a criminal record clearance and be associated to the facility prior to working in the licensed child care program.

Licensee was reminded that CPR/First Aid and Mandated Reporter training must be renewed every two years.

Licensee 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).

Licensee 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. Licensee states there is no smoking in the facility.

The following were also discussed with the licensee:

Page 4

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 6 of 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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: - Licensee Melissa Azose 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.

Assembly Bill 633: Upon receipt of a citation for a Type A Deficiency, the director shall post the licensing report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report (LIC 809D/9099D) to parents/guardians of children in care at the facility by the close of business the following day or the next day child returns to the facility. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file.

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:

Page 5

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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

Safe Sleep: - LPA discussed the safe sleep regulations with Licensee Melissa Azose 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 Melissa Azose 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): - 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/.

California Department of Social Services | Community Care Licensing Division
300 Continental Blvd. Suite 290 A
El Segundo, CA 90245

MyChildCarePlan.org: – Licensee Melissa Azose 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.

Megan’s Law: - During the exit interview, the Licensee Melissa Azose, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS 06/18/2026.

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.

Page 6

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 8 of 9

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: AZOSE FAMILY CHILD CARE	FACILITY NUMBER: 197495123
	VISIT DATE: 06/18/2026

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

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.

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

At this time, citations are being issued today. See LIC 809D

A notice of site visit was given and must remain posted for 30 days. This report shall be made available to the public upon request.

Appeal Rights provided

Exit interview conducted and report was reviewed with the Licensee Melissa Azose

Page 7

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Decondia Ferguson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

Page: 9 of 9