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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608029
Report Date: 03/21/2024
Date Signed: 03/21/2024 11:17:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210831121113
FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 231DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ADMINISTRATOR JANIE ACOSTATIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained a pressure injury while in care
Staff left resident in soiled diaper for extended period of time
Facility has roaches
INVESTIGATION FINDINGS:
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On 05/04/2023 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta with Vista Del Mar Senior Living and the purpose of the visit was explained.
During this investigation, LPA Calderon interviewed Administrator (A1), residents (R1-R20), staff (S1-S7). These interviews were conducted on 01/25/2023. On 08/31/2021 LPA Calderon obtained copies of Staff and Resident rosters, Medication Administration Records (MAR) (08/17/2021), Needs and Service plan (01/20/2021), Physician Report (02/09/2021) for R1 and pest control invoices (June to August 2021) for facility. On 8/31/21, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Peter Zertuche was assigned to this case. On 10/07/2021 Investigator Zertuche provided an IB report after concluding IB’s investigation.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation #1: Resident sustained a pressure injury while in care.


This complaint alleges that R1 sustained a pressure injury while in care: the investigation revealed that Resident #1 formed a Stage III pressure injury on its coccyx beginning 08/23/21; and it quickly progressed to Stage IV by 09/02/21. Resident #1 had been receiving hospice care since 03/03/21 for an unrelated issue. Facility staff were instructed to reposition Resident #1 every two (2) hours due to the resident’s status of Bedridden. The wound worsened over the next week – while the resident continued to reside in the facility – with no new hospice care plan or wound training. The facility was directed to reposition Resident #1 every two (2) hours; but according to Witness #1 (Hospice Care Nurse), the reposition chart was not being followed; and, it had missing initials in spaces where the resident was supposed to be turned and its pressure injury was listed as Stage IV by 09/02/21. Resident #1’s health was in decline and the facility continued to retain Resident #1 with a prohibited health condition until its passing on 09/03/21.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED.



At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation #2: Facility has roaches.

This complaint alleges that the facility has roaches. LPA Calderon conducted an interview with A1. A1 expresses that residents have advised that there are roaches in certain rooms. A1 expresses that staff sprays certain rooms, and that pest control is called, and pest control company sprays the building and rooms for roaches and other bugs. LPA Calderon conducted an interview with S2-S7. S5, S6 and S7 have seen roaches in the building but expressed that pest control comes monthly and sprays for roaches. LPA Calderon conducted an interview with R1-R20. R2, R7 and R10 have seen roaches in their room. Residents called staff and pest control came out and sprayed their rooms. R1 and R13 have seen roaches in the dining room while eating food. Pest control came out and when the dining room was closed sprayed the dining room area. R4 states that R4 noted seeing roaches in the patio area. On 01/25/2023 LPA Calderon reviewed pest control paperwork that stated that pest control company sprayed roaches in the facility.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care 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).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation 3: Staff left resident in soiled diaper for extended period.

This complaint alleges R1 diaper was not changed timely.

LPA Calderon conducted an interview with A1. A1 expressed that R1’s incontinence care occurred 3 times per shift. A1 was unable to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. R1 was receiving hospice care for the pressure ulcer and pre-existing health condition; however, the facility failed to update the hospice care plan to reflect incontinence needs. LPA Calderon was unable to obtain documented incontinence care instructions and staff training for R1’s incontinence care. Based on interviews conducted and lack of records provided to support R1’s incontinence needs were met according to Hospice orders, LPA Calderon found sufficient evidence to support the above-mentioned allegation and finds this allegation “Substantiated”.

Based on interviews, observations and supporting documents facility staff failed to ensure a physicians order/hospice care plan were in place to address R1 pressure injury by an appropriate skilled medical professional The preponderance of evidence standard has been met; therefore, the allegation of “resident sustained a pressure injury while in care” and “facility has roaches”, “Staff left resident in soiled diaper for extended period”, 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 citations issued (ref LIC9099D)

A face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions (a) Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by: Facility retained Resident #1 with a Stage IV pressure injury on its coccyx (a prohibited health condition) until the resident passed away on 09/03/21. This requirement was not met as evidenced by
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Licensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immeLicensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/El Segundo ASC Office no later than 03/22/2024.
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Based on records reviewed and interviews conducted the licensee failed to care for resident with stage 3 and 4 pressure sores. This poses a Safety risk to residents in care.
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CCR
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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair always…
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The administrator will provide pest control reports for a 3-month period and log pest control reports to LPA Calderon by the due date of 03/29/2024.

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Based on records reviewed and interviews conducted, the licensee failed to control roaches inside the facility for residents in care. This poses a Safety risk to residents in care.

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Type B
03/29/2024
Section Cited
CCR
87612(a)(7)
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87612(a)(7) Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (7) Incontinence of bowel and/or bladder as specified in Section 87625. This requirement was not met as evidenced by

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The administrator will provide training to staff on how to document the incontinence log notes for residents in care by the due date of 03/29/2024.

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Based on records reviewed and interviews conducted the licensee failed to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. This poses a Safety risk to residents in care.

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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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210831121113

FACILITY NAME:VISTA DEL MAR SENIOR LIVINGFACILITY NUMBER:
197608029
ADMINISTRATOR:BRAD DEHAANFACILITY TYPE:
740
ADDRESS:3360 MAGNOLIA AVENUETELEPHONE:
(562) 595-1559
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:300CENSUS: 231DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ADMINISTRATOR JANIE ACOSTATIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not adminster the correct medication dosage to resident
Staff leave food in resident's room for extended period of time
INVESTIGATION FINDINGS:
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On 05/04/2023 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta with Vista Del Mar Senior Living and the purpose of the visit was explained.
Investigation consisted of the following: LPA Calderon interviewed Janie Acosta Administrator (A1), residents (R2-R20), staff (S1-S7). These interviews were conducted on 01/25/2023. On 08/31/2021 LPA Calderon obtained and reviewed the following: Medication Administration Records (MAR) (dated 08/17/2021), Needs and Service plan (dated 01/20/2021), Physician Report (dated 02/09/2021) for R1 and pest control invoices (dated June to August 2021) for facility. On 8/31/21, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Peter Zertuche was assigned to this case. On 10/07/2021 Investigator Zertuche provided an IB report after concluding IB’s investigation.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation #1: Staff did not administer the correct medication dosage to residents.

This complaint alleges the facility failed to increase R1 medication dosage per a physician’s order.

LPA Calderon conducted an interview with Janie Acosta (A1). A1 stated R1’s medications were administered per doctors’ orders. LPA Calderon obtained and reviewed R1’s Medication Administration Record (MAR) and found 7 out of 8 medications were not administered on 08/25/21 and 08/26/21. LPA Calderon was unable to find or obtain a record of a doctor’s order indicating a change in any of the medication dosages. LPA obtained and reviewed a PRN Authorization Letter dated 2/9/21 and signed by the Hospice Medical Director. The PRN Authorization Letter states Hydrocodone Bitartrate and Loperamide can be taken added to R1’s PRN’s. These medications were found in the PRN section on R1’s MAR. LPA Calderon conducted an interview with 3 Staff members who handle Resident medications. LPA Calderon conducted interviews with 6 staff members. LPA found 6 out of 6 staff members did not report medication dosage issues. LPA Calderon conducted an interview with 20 Residents. LPA Calderon found 3 out of 20 Residents stated having experienced issues with medication administered; however, corrections were made, and issues resolved by the facility. LPA Calderon found 17 out of 20 Residents have not experienced issues with medication administered. Based on records obtained and interviews conducted, LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 11-AS-20210831121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VISTA DEL MAR SENIOR LIVING
FACILITY NUMBER: 197608029
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation #2: Staff leave food in residents’ room for extended period.

This complaint alleges that staff leave food trays in R1’s room and this is contributing to a roach problem.

LPA Calderon conducted an interview with A1 who expressed that R1 receives tray service for all meals as R1 is bedridden. A1 stated staff will retrieve the food tray 3 times per day from R1’s room. A1 stated that roaches have been present in the facility and pest control is employed for this reason. LPA Calderon conducted an interview with Staff S2-S7 and found 3 out of 6 staff expressed that some residents prefer to eat in their rooms and food trays are retrieved from the Resident rooms timely. S5-S7 expressed that S5-S7 follows up with dining staff to make sure food trays are picked up timely. LPA Calderon conducted interviews with Residents R2-R20 for complaint and found 19 out of 20 residents either received tray service and expressed tray pick-up occurred timely or eat meals in the facility dining room; therefore, they were unable to speak to the timeliness of tray retrieval by staff. , LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”.


Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations “staff did not administer the correct medication dosage to resident” “staff leave food in residents’ room for extended period” did or did not occur, therefore the allegations is UNSUBSTANTIATED.

A face-to-face meeting was conducted with Administrator Janie Acosta A1, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10