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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 03/03/2023
Date Signed: 03/03/2023 12:10:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Perry Scott
COMPLAINT CONTROL NUMBER: 11-AS-20211223133911
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
197607682
ADMINISTRATOR:CRYSTAL PAKFACILITY TYPE:
740
ADDRESS:325 N. HAYWORTH AVENUETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Crystal PakTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Illegal Eviction.
Financial abuse.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Perry Scott met with Administrator (A1: Crystal Pak) during an Office Meeting at the El Segundo Adult & Senior Care Office to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: An initial 10-Day visit was conducted by LPA Jade Jordan on 12/29/21 with Staff #1 as the Administrator (Crystal Pak) was unavailable at the time of this visit. The investigation consisted of interviews with facility staff and records review. LPA Jordan requested documents pertinent to the investigation: Admissions Agreement, Physician’s Report, Appraisal/Needs and Services Plan, Emergency I.D. Information, Resident Safeguard for Cash Resources, Staff Work Schedule & Roster, and Residents’ Roster. A separate investigation was conducted by the Department of Social Services Audit Bureau (Lisa Ni) which included a review of Resident #1’s payment history (period from December 2019 up to April 2020), bank account records (period from December 2019 up to May 2022), checking summary/transaction details (period from 12/25/19 up to 05/24/22), account statements (period from January 2021 up to October 2021), and Property Report (Assessment & Deeds). On 3/1/2022 LPA interviewed the Administrator Crystal Pak.
Continued on LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 03/03/2023
NARRATIVE
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Regarding Allegation #1: this investigation revealed that Resident #1 (R1) was admitted to the facility on 05/05/16 and occupied a semi-private room for One-thousand Two-hundred Dollars ($1,200) per month. Resident #1 was their own responsible person for themself and paid their own rent by cash. According to records reviewed Resident #1 left the facility on 04/03/2020 and moved out to another place as resident wishes. LPA interviewed the Administrator and A1 stated she is not aware of why R1 was not admitted back to the facility since she did not work for the facility at that time. A1 stated it is noted in R1 file R1 moved of his own wishes. Staff #1 confirmed that R1 left the facility on 04/03/2020 and all of R1’s belongings were at the facility. Administrator (Crystal Pak) stated that R1 packed their own stuff and left on their own. On 12/30/2020, Staff #1 received a call from LAPD – Hollywood Division inquiring if Resident #1 could return to the facility; and, Staff #1 advised the police officer that at this time, the facility was unable to accept R1 due to the COVID pandemic outbreak. Staff #1 proceeded to provide the police officer with the name of another facility (LM-Guest Home); of which, R1 left after two (2) days. Staff #1 (then) recommended Heavenly Living Independent facility to R1.

Based on interviews conducted, records review and observation R1 belongings remained at the facility after R1 allegedly moved out. There was no evince that the facility staff followed the proper procedures for discharge of a resident. Based on interview the facility failed to accept R1 back and assisted with placing R1 in an unlicensed locations although R1 required care and supersvision.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of EVICTION/DISCHARGE: Illegal Eviction is found to be SUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Staff #1 financially abused Resident #1 (R1) by obtaining R1’s debit card, pin number, and withdrawing cash (via ATM) from R1’s bank account. An audit was conducted of R1’s bank account records (period from December 2019 up to May 2022), checking summary/transaction details (period from 12/25/19 up to 05/24/22), and account statements (period from January 2021 up to October 2021). Staff #1 inappropriately obtained R1’s debit card, pin number, and withdrew Thirteen-thousand Eight-hundred Dollars ($13,800) from R1’s bank account. Staff #1’s Venmo statement showed Seven-thousand Five-hundred Fifty Dollars ($7,550) was paid to the owner of Heavenly Living Independent Living for the period from January 2021 to August 2021. The Six-thousand Two-hundred Fifty Dollars ($6,250) variance was noted. The amounts of withdrawal from R1’s bank account did not agree with the amounts of rent paid to the owner of Heavenly Living


Independent Living.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 03/03/2023
NARRATIVE
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The account was used for Resident #1’s receiving SSA payments and VA benefits. The bank statements were reviewed as follows:
Bank Statement Period: 03/25/2020 – 12/23/ 2020
R1 left facility on 04/03/2020. From 04/24/2020 to 12/23/2020, R1 made two (2) cash
withdrawals for Sixty Dollars ($60) and Three-hundred Dollars ($300). On 12/23/2020, R1 had account accumulated balance for Ten-thousand Eighty-one Dollars ($10,081).

Bank Statement Period: 12/24/2020 – 01/27/2021
S1 using R1’s debit card withdrew Five-hundred Dollars ($500) on 01/02/2021 and Seven-hundred Fifty Dollars ($750) on 01/04/2021 and Two-hundred Dollars ($200) on
01/09/2021 for totaling One-thousand Four-hundred Fifty Dollars ($1,450). Auditor requested S1 to provide R1’s rent receipt, rental agreement/admission agreement or other supporting documentation to substantiate the withdrawal amount that was paid for R1’s rent. S1 only provided an account statement; and, it showed Fifty Dollars ($50) transferred on 01/16/2021. The account statement did not show an account number and account name. The account statement is invalid documentation. The detail property report for the property (unlicensed Heavenly Living Independent Living) located at 11131 Leadwell St, Sun Valley, CA 91352 was sold on 08/09/2021. The rent S1 claimed One-thousand Two-hundred Fifty Dollars ($1,250) did not agree with the amount withdrawal. There was a Two-hundred Dollar ($200) variance ($1,450 – 1,250).

Bank Statement Period: 01/28/2021 – 02/24/2021
S1 using R1’s debit card withdrew One-hundred Dollars ($100) and Seven-hundred Dollars ($700) on 02/02/2021 and Five-hundred Dollars ($500) on 02/04/2021 for totaling One-thousand Three-hundred Dollars ($1,300). Auditor requested S1 to provide R1’s rent receipt and other supporting documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was unable to provide it. The rent S1 claimed One-thousand Two-hundred Fifty ($1,250) did not agree with the amount withdrawal. There was Fifty Dollar ($50) variance ($1,300 – 1,250).


Continued on LIC9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2023
Section Cited
CCR
87468.2(26)(A)
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) Additional Personal Rights of Residents in Privately Operated Facilities (26) To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided for in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (A) Accept appointment as a guardian or conservator of the person or estate of a resident. This requirement is not met as evidence by:
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Licensee/Administrator shall read Title 22, Section 87468.2 "Additional Personal Rights of Residents in Privately Operated Facilities" and send a written statement to CCLD by the POC date. The plan is due to the CCLD/El Segundo ASC Office by POC date of 03/04/23.
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Staff #1 inappropriately obtained R1’s debit card, pin number, and withdrew Thirteen-thousand Eight-hundred Dollars ($13,800) from R1’s bank account. The monthly cash withdrawals did not agree with R1’s monthly rent which Staff #1 claims. This poses a personal rights risk to residents In care.
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Type B
03/11/2023
Section Cited
CCR
87405(d)(1-7)
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If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidence by:
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Licensee/Administrator shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD by the POC date. The plan is due to the CCLD/El Segundo ASC Office by POC date of 03/11/23.
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 Administrator failed to safeguard resident’s cash resources.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2023
Section Cited
CCR
1569.683(a)(3)(4)
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In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction...This requitrement is not met as evidenced by:
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The administrator/licensee shall review the health and safety codes regarding evictions and submit a statement acknowledging the section of eviction procedures.
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Facility refused to take Resident #1 back when found walking in and out of traffic on 12/30/20 by LAPD – Hollywood Division Police Officer. Staff #1 confirmed (via telephone on 10/24/2022) that R1 left the facility on 04/03/2020 and all of R1’s belongings were at the facility.
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Type B
03/11/2023
Section Cited
CCR
87405(d)(1-7)
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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidence by:
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Licensee/Administrator shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD by the POC date. The plan is due to the CCLD/El Segundo ASC Office by POC date of 03/11/23.
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Administrator failed to ensure that the resident was placed in an appropriate facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 03/03/2023
NARRATIVE
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Bank Statement Period: 02/25/2021 – 03/23/2021
S1 using R1’s debit card withdrew Seven-hundred Dollars ($7000 on 03/01/2021 and Five-hundred Dollars ($500) on 03/02/2021 for totaling One-thousand Two-hundred Dollars ($1,200). Auditor requested S1 to provide R1’s rent receipt and other supporting
documentation to substantiate the withdraw amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided account statement without a name and
account number showed One-thousand Two-hundred Fifty Dollars ($1,250) was transferred to the unlicensed operator on 3/2/2021. The amount withdrawal did not agree with the rent S1 claimed. There was a Fifty Dollar ($50) variance ($1,200 - $1,250).

Bank Statement Period: 03/24/2021 – 04/23/2021
S1 using R1’s debit card withdrew $100, $200, $500 on 4/1/2021 and $500 on 4/4/2021
for totaling $1,300. Auditor requested S1 to provide R1’s rent receipt and other
supporting documentation to substantiate the withdrawal amount was paid for R1’s rent.
S1 was unable to provide rent receipt. S1 provided an account statement without
account name and account number showed $1,250 transferred to the unlicensed operator on
4/1/2021. The amount withdrawal did not agree with the rent S1 claimed. There was
variance for $50 ($1,300 - $1,250).

Bank Statement Period: 04/24/2021 – 05/25/2021
S1 using R1’s debit card withdrew $1,000 on 4/29/2021 and $1,000 on 5/2/2021 for
totaling $2,000. Auditor requested S1 to provide R1’s rent receipt and other supporting
documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided an account statement without account name
and account number showed $1,250 transferred to Gevory Bakhrjyan on 5/1/2021. The
amount withdrawal did not agree with the rent S1 claimed. There was variance for $750
($2,000 - $1,250).


Continued on LIC9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 03/03/2023
NARRATIVE
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Bank Statement Period: 05/26/2021 – 06/23/2021
S1 using R1’s debit card withdrew $1,000 on 5/30/2021 and $500 on 6/6/2021 for
totaling $1,500. Auditor requested S1 to provide R1’s rent receipt and other supporting
documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided an account statement without account name
and account number showed $1,250 transferred to the unlicensed operator on 6/1/2021. The
amount withdrawal did not agree with the rent S1 claimed. There was variance for $250
($1,500 - $1,250).
Bank Statement Period: 06/24/2021 – 07/26/2021
S1 using R1’s debit card withdrew $1,000 on 6/26/2021. Auditor requested S1 to
provide R1’s rent receipt and other supporting documentation to substantiate the
withdrawal amount was paid for R1’s rent. S1 was unable to provide any
documentation. The amount withdrawal did not agree with the rent S1 claimed. There
was variance for $250 ($1,000 - $1,250).
Bank Statement Period: 07/27/2021 – 08/24/2021
S1 using R1’s debit card withdrew $1,000 on 8/2/2021 and $500 on 8/7/2021 for totaling
$1,500. Auditor requested S1 to provide R1’s rent receipt and other supporting
documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided an account statement without account name
and account number showed $1,250 transferred to the unlicensed operator on 8/2/2021. The
amount withdrawal did not agree with the rent S1 claimed. There was variance for $250
($1,500 - $1,250). It should be noted unlicensed Heavenly Living Independent Living
property was sold on 8/9/2021.
Bank Statement Period: 08/25/2021 – 09/24/2021
S1 using R1’s debit card withdrew $1,000 on 8/30/2021 and $250 on 9/4/2021 for
totaling $1,250. Auditor requested S1 to provide R1’s rent receipt and other supporting
documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided an account statement without account name
and account number showed $1,250 transferred to unlicensed operator on 8/2/2021. The
amount withdrawal agreed with the rent S1 claimed.

Continued on LIC9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20211223133911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 03/03/2023
NARRATIVE
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Bank Statement Period:0 9/25//2021 – 10/26/2021
S1 using R1’s debit card withdrew $1,000 on 9/28/2021 and $300 on 10/2/2021 for
totaling $1,300. Auditor requested S1 to provide R1’s rent receipt and other supporting documentation to substantiate the withdrawal amount was paid for R1’s rent. S1 was
unable to provide rent receipt. S1 provided an account statement without account name
and account number showed $1,250 transferred to the unlicensed operator on 10/2/2021.
The amount withdrawal did not agree with the rent S1 claimed. There was variance for
$50 ($1,300 - $1,250). S1’s statement did not agree with R1’s financial records. The monthly cash withdrawal did not agree with the rent S1 claimed. S1 started using R1’s debit card to pull out cash on 1/2/2021, and the last time cash withdrawal was on 10/2/2021. From 1/2/2021 to
10/2/2021, S1 withdrew $13,800 from R1’s bank account via Chase Bank ATM. S1’s
Venmo statement showed $7,550 was paid to owner of Heavenly Living Independent
Living for the period from January 2021 to August 2021 including $50 for the month of
January 2021, $1,250 for the month of March 2021, $1,250 for the month of April 2021,
$1,250 for the month of May 2021, $1,250 for the month of June 2021, $1,250 for the
month of July 2021, $1,250 for the month of August 2021. It should be noted Heavenly
Living Independent Living property was sold on 8/9/2021, and August 2021 rent was
paid on 8/2/2021 for $1,250 The difference between amount withdrawal from R1’s bank
account and amount rent paid to owner of Heavenly Living Independent Living is $6,250
($13,800 - $7,550). After Heavenly Living Independent Living property sold, S1 still
withdrew the cash from R1’s account in the months of September and October 2021.

Based on the evidence gathered and interviews conducted and audit records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of FINANCIAL ABUSE: Financial Abuse is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator (Crystal Pak).

















SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8