<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495233
Report Date: 10/28/2024
Date Signed: 10/29/2024 03:42:46 PM

Document Has Been Signed on 10/29/2024 03:42 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:KIDDIE KOLLEGE INC.FACILITY NUMBER:
197495233
ADMINISTRATOR/
DIRECTOR:
BROWN, AVAFACILITY TYPE:
830
ADDRESS:2639 W. MANCHESTER BLVD.TELEPHONE:
(323) 636-6416
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 13TOTAL ENROLLED CHILDREN: 13CENSUS: 11DATE:
10/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Ava BrownTIME VISIT/
INSPECTION COMPLETED:
04:30 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 10/28/2024, Licensing Program Analyst (LPA) Ranita Richmond conducted an unannounced Required / Annual Inspection for the above-named Infant Child Care Center. Center is licensed for 4 infant children, ages 0 thru 24 months of age and 9 toddlers, ages 18-36 months. LPA met with Director Ava Brown. LPA Richmond toured the facility indoors and outdoors and observed 11 children in care, being supervised and cared for appropriately by 4 fingerprint cleared staff members. Facility hours of operation are Monday – Friday, 7:00am – 5:00pm.

Capacity and limitations as specified on the license are being maintained.


All children are under visual supervision of a teacher at all times. The CCC is in compliance with Title 22 regulations regarding Staff to Student ratios. LPA reviewed the sign in/ sign out sheets located on the front counter of the facility. LPA observed children being signed in using signatures and times. LPA Richmond advised Director of the importance of sign in/sign out using the full first and last name of the parent/authorized representative and time of checking the child in and out daily.

Kitchen on site. All chemicals, poisons, sharp objects, or other hazardous items are accessible to children in care by locked cabinets, safety gates, and visual supervision. Kitchen is made inaccessible to children in care by locked doors and visual supervision.

There is one crib present for each infant in care. Cribs were not free of all loose articles and objects, including blankets and pillows. Type B citation cited. Cribs were not free of objects hanging above or attached to the side of the crib. Type B citation cited. All bedding used for only the child assigned. All soiled bedding shall be replaced when wet or soiled. Soiled bedding shall be placed in a suitable container and made inaccessible to infants until washed.

There are no swimming pools, ponds, or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible.

LPA Richmond observed 1 (one) fully charged 3A:40B:C fire extinguisher in the kitchen and at the entrance of the building in the lobby area. LPA Richmond observed working carbon monoxide and smoke detectors throughout the site.

page 1 of 3

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101439.1(f)
Infant Care Center Sleeping Equipment
(f) Cribs shall be free from all loose articles and objects, including blankets and pillows.

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 1 out of 2. Pillows in the crib which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will ensure all objects are removed from cribs at all time.
Type B
Section Cited
CCR
101439.1(f)(3)
Infant Care Center Sleeping Equipment
(f) Cribs shall be free from all loose articles and objects, including blankets and pillows. (3) There shall be no objects hanging above or attached to the side of the crib.

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 2 out of 2. Bibs hanging from the cribs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will ensure that no objects are hanging from the cribs.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

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 1 out of 2. Poisons not stored in locked storage areas which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will keep poisons in locked storage areas.
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2. Infant sleep chart not available with documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will document sleep checks on sleep chart every 15 minutes daily.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)(3)(a)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: (3) Infants up to 12 months of age who are sleeping in a position other than on their back. (a) If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, staff shall return the infant to their back for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2. LIC 9227 not available in children files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will complete LIC 9227 forms for all infants enrolled.
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
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2. Staff immunizations not present in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff files will be updated with staff immunizations to include mmr, tdap, and flu.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Director will ensure at least one staff is trained in cpr/1st aid
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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
1
2
3
4
Staff will complete mandated reporter training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2. Admission agreements missing from childrn's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2. LIC 627 not present in children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Staff will have parents complete LIC627 and place in files.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/29/2024 03:42 PM - It Cannot Be Edited


Created By: Ranita Richmond On 10/28/2024 at 03:15 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: KIDDIE KOLLEGE INC.

FACILITY NUMBER: 197495233

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1. Infant needs and services plan is missing from children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Director will create an infant needs and services plan for parents to complete. Infant needs and services plan will be placed in children's files.
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.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KIDDIE KOLLEGE INC.
FACILITY NUMBER: 197495233
VISIT DATE: 10/28/2024
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
All toilets and hand washing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. LPAs inspected the classrooms and observed age-appropriate toys, books and furnishings. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. Playground equipment is in safe condition, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards.

CCC provides all meals, snacks, and water. Solid waste storage containers have tight-fitting covers and are in good repair.

LPA Richmond reviewed 4 children’s files. Files will be reviewed by director for completion. Type B citation cited due to files missing LIC 9227, infant needs and services plan, and LIC 627.

LPA Richmond reviewed 4 personnel files. 4/4 files missing 1st aid/cpr which poses an immediate Health, Safety and, Personal Rights risk to persons in care. Type B citation cited. LPA reminded Director that CPR/First Aid is to be EMSA approved and both CPR/First Aid and Mandated Reporter training are to be renewed every 2 years. LPAs provided director with LIC311A and LIC125 to use as a reference when auditing files.

CCC HAS NOT COMPLETED LEAD TESTING.

Director 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.



This facility does not provides Incidental Medical Services - IMS.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care­ centers/.


Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

page 2 of 3
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 9 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KIDDIE KOLLEGE INC.
FACILITY NUMBER: 197495233
VISIT DATE: 10/28/2024
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 Richmond reminded Director to access the Community Care Licensing website www.ccld.ca.gov for access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.


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.

LPA offered TSP services to Director Ava Brown. Director accepted referral.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, citations were cited today. See LIC 809D.


Exit interview conducted, and report was reviewed with Director Ava Brown.
Appeal rights printed and reviewed with Director Ava Brown.
A Notice of Site Visit was provided and must remain posted for 30 days.

page 3 of 3
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9