197609518-12-23-2024-29-AS-KLOZ-DCG92E-20241230215902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 12/20/2024
Date Signed: 12/23/2024 08:37:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230612083135

FACILITY NAME:	BELMONT VILLAGE CALABASAS		FACILITY NUMBER:	197609518
ADMINISTRATOR:	NELSON, NANCY		FACILITY TYPE:	740
ADDRESS:	24141 VENTURA BLVD		TELEPHONE:	(818) 222-2600
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	165	CENSUS: 129	DATE:	12/20/2024
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Nancy Nelson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff not trained to meet residents’ incontinence needs.
Staff inappropriately handle residents in care.
Staff speak inappropriately to residents in care.
Staff do not afford residents in care dignity and respect.
Residents had unexplained bruises.
Residents’ needs are not being met.
Residents is not residing in an appropriate setting.
Administrator does not have knowledge of applicable laws and/or regulations.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced complaint investigation visit at the facility to investigate the allegations listed above. LPA Urena met with Nancy Nelson, Executive Director (ED) at 1:45 p.m., and explained the reason for the visit.

On 06/16/2023, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint inspection at the facility today regarding the above allegations. The LPA met with Administrator Nancy Nelson at 12:19 PM and explained the reason for the inspection.

Continues on LIC 9099 (pg.2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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Pg. 2
Staff not trained to meet residents’ incontinence needs.
On the allegation that staff are not trained to meet residents’ incontinent needs; it is the concern of the reporting party (RP) that the staff force residents when addressing incontinence needs. On 06/16/2023, LPA Lopez interviewed the RP, and the RP stated that staff and administrator said it’s okay to hold down, or force residents when assisting with incontinence needs. On 08/08/2024, LPA Urena interviewed Nancy Nelson, Executive Director (ED) at 1:45 p.m. Per the ED, the staff receive training on how to address incontinence needs for residents with dementia. It is part of the initial training staff receive. The training is an on-line training (Total Incontinence Management Program (TIM)). Caregivers watch all training videos prior to this validation process. Once caregivers successfully complete the validation checklist, they will then complete a final exam to become TIM certified. The ED denied making such comments. The LPA reviewed training records for five facility staff, and the record review revealed that staff successfully completed incontinent training. Furthermore, the LPA interviewed staff about the process of assisting residents who resist incontinence care. The interviews revealed that the staff may try different techniques to engage the residents to agree to the incontinent care. The staff may distract the residents with questions, or by showing them items that may attract the resident, or ask another staff to assist, “sometimes, a different face, or voice may get the resident to cooperate”. The staff stated that they check residents every two hours and change the diapers as needed. Staff denied forcing or holding down residents while addressing incontinence needs.

Although the allegation may have happened or is valid, based on the interviews and record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Continues on LIC 9099 (Pg. 3)

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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(Pg. 3) Staff inappropriately handle residents in care.
On the allegation that staff inappropriately handle residents in care; it is the concern of the reporting party (RP) that facility staff force or hold down the residents’ arms while changing their clothing. On 06/16/2023, LPA Lopez interviewed the RP, and the RP stated that staff and administrative stated it’s okay to hold down, or force residents because residents have ‘dementia’. On 08/08/2024, LPA Urena interviewed Nancy Nelson, Executive Director (ED) at 1:45 p.m. Per the ED, the staff learn techniques on how to address residents’ behavior, condition, and to treat residents with respect and dignity, as part of their on-line training. LPA Urena reviewed staff training records, and record review revealed that staff receive training that follows departments regulations. Furthermore, the facility has a skill validation process/checklist, which includes new staff being observed and graded by a designated experienced facility staff. The new staff must follow and complete all tasks in the five (5) page checklist to pass the probationary period. LPA Urena interviewed staff about the process of assisting residents in the memory care unit. The interviews revealed that the staff may try different techniques to engage the residents to agree to the care provided. The staff may distract the residents with questions, or by showing them items that may attract the resident, or ask another staff to assist, “sometimes, a different face, or voice may get the resident to cooperate”. Staff denied using force while assisting residents with dressing.

Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Staff speak inappropriately to residents in care.

On the allegation that staff speak inappropriately to residents in care, it is the concern of the RP that staff violate residents’ personal rights by using inappropriate language, while assisting residents with ADL needs. LPA Urena was unable to interview S1 and S3 as they no longer work for the facility. The LPA interviewed S4 about the allegation and S4 denied speaking in an unrespectful way to residents. The LPA interviewed S2 about witnessing inappropriate language used by other staff, and S2 denied witnessing inappropriate behavior. The LPA interviewed the ED about the concerns with staff’s inappropriate behavior, and the ED stated that if staff is reported to them the concerns are sent to the Human Resources Department and addressed accordingly.
Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Continues on pg. 4

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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Pg. 4 Staff do not afford residents in care dignity and respect.
On the allegation that staff do not afford residents in care dignity and respect, it is the concern of the RP that staff (S3) use negative reinforcement techniques to get residents to comply with the staff’s commands, consequently, disrespecting the residents in care. On 06/12/2023, LPA Lopez interviewed the RP, and the RP said they told the ED about the negative reinforcement techniques, and the ED said it was just a joke and the RP wouldn't understand. LPA Urena interviewed the ED about the comments made to the RP, and the ED denied the comments. LPA Urena was unable to interview S3 as the staff is no longer employed by the facility.
Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Residents had unexplained bruises.
On the allegation that residents had unexplained bruises, it is the concern of the RP that they do not think the bruises observed on residents’ arms and legs are from a fall, but rather from staff being rough with the residents. On 06/12/2023, LPA Lopez met with Interim Director of Nursing (DN) Zara Khatchetarian during record review. The DN said all five residents’ records reviewed use "Safely You". DN said only R2 and R3 had reported falls from Safely You during the month of May. The notes from the falls are documented in the nurses’ notes. R2 had a recorded fall on 05/23/2023 but there was no injury. R3 had a recorded fall on 05/28/23 but R3 was only observed sitting on the floor and there was no actual fall. And on 05/31/2023, R3 was found with agitation and with a skin tear. Although, nursing notes reflect no fall for R2 on 05/23/2023 or for R3 on 05/28/2023. LPA Urena was unable to interview the DN, as they are no longer employed at the facility.

Although the allegation may have happened or is valid, based on the interviews, observation, record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.
Continues pg. 5

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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Pg. 5
Residents’ needs are not being met.
On the allegation that Residents’ needs are not being met. It is the concern of the RP that a resident’s (R4) urine bag was not emptied because staff said they were not trained on how to do it. On 06/12/2023, LPA Lopez, interviewed the RP, and they said that Assisted Living (AL) staff S2 was working in memory care and did not empty a resident’s urine bag, because they were not trained on how to do it. On 08/08/2024, LPA Urena interviewed S2 regarding the training received for catheter care. The S2 stated that they had received training on how to ensure good hygiene and changing/emptying with various catheter types. Furthermore, LPA Urena reviewed training records for S2. The record review revealed that S2 had received training and had passed the Competency Skill Validation test on 04/06/2023.
Based on the information obtained through interviews and record review, the facility provided training to S2 on the process for catheter and urine bag care. Therefore, the allegation is deemed Unsubstantiated at this time.
Resident is not residing in an appropriate setting.
On the allegation that a Resident is not residing in an appropriate setting, the concern of the RP is that R1 was moved from AL to the memory care and the RP does not think R1 belongs in MC. RP said the resident is cognitive and independent with their ADLs. To investigate the allegation, LPA Urena reviewed R1’s medical records, and emails and communication between the ED and R1’s POAs. Medical records indicate that R1 was diagnosed in 2021 with mild cognitive impairment and by 2023 R1 was diagnosed with Alzheimer’s. LPA Urena interviewed the ED, and the ED, stated that R1 began to show signs of decline in mental alertness. Furthermore, the ED stated that a clinical test, the Montreal Cognitive Assessment (MoCA) was administered to R1. The results of the test showed a dramatic decline between 04/26/2021 and 01/11/2022. The concerns for R1 were brought up to R1’s POAs. The ED began communication with R1’s POAs about moving R1 from the Assisted Living (AL) to the Memory Care (MC), started via email on May 3, 2023. In the email, the ED expresses concern for R1’s decline and offers the possibility of moving R1 to the MC. The POAs agreed the move for R1 from the ALC to the MCU approximately on May 22, 2023. Although, in June 2023, communication between the POA (and the facility Activities and Memory Care Specialist) states the concern for R1 is to continue to attend as many activities as R1 is interested in attending in the AL (with assistance from a private caregiver), as agreed in communication with the ED.
Based on the information obtained through record review and interview, R1’s POAs agreed to have R1 transferred from the AL to the MC. Therefore, the allegation is deemed Unsubstantiated at this time.
Continues on Pg. 6

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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Pg. 6
Administrator does not have knowledge of applicable laws and/or regulations.
On the allegation that the Administrator does not have knowledge of applicable laws and regulations, the concern of the RP, is that the ED stated that caregivers/staff are not mandated reporters. LPA Urena conducted record review to verify the ED’s certification is valid and up to date, and the record review revealed that the ED completed the Residential Care for the Elderly Administrator Certification Program, which was valid Effective: 06/18/2022, with an Expiration Date of: 06/17/2024. The LPA interviewed the ED about their knowledge of the mandated reporter’s role, and about anyone with knowledge of abuse towards the elderly. The ED stated that they understood that anyone can make a report to the CCLD department, and do not necessarily have to be a mandated reporter. The ED denied making statements about staff/caregivers not being mandated reporters. The LPA interviewed staff about their knowledge of making reports to the CCLD department if they observe any type of abuse towards the residents, and staff stated that they were aware of the hotline to make reports if they saw any unprofessional behavior or any type of abuse.

Based on the information obtained through record review and interviews, there is not sufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, and a copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230612083135

FACILITY NAME:	BELMONT VILLAGE CALABASAS		FACILITY NUMBER:	197609518
ADMINISTRATOR:	NELSON, NANCY		FACILITY TYPE:	740
ADDRESS:	24141 VENTURA BLVD		TELEPHONE:	(818) 222-2600
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	165	CENSUS:	DATE:	12/20/2024
		UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Nancy Nelson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Residents are not receiving assistance timely.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 12/20/2024

NARRATIVE

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Residents are not receiving assistance timely.
On the allegation that residents are not receiving assistance timely, it is the concern of the RP that residents are not receiving assistance right away due to a lack of keys available for staff to use to access the residents’ rooms, consequently residents can be heard calling staff for assistance, but staff cannot get to them due to not having access to a set of keys, staff with keys leaving the facility premises, and not leaving the keys for the standing staff.

On 06/16/2023, LPA Lopez interviewed the ED, who confirmed all resident doors in AL and Memory care lock automatically from the outside, but residents are able to get out from the inside. During the physical plant tour, LPA Lopez tested a room and was able to exit the room from the inside. A key is currently needed to unlock the door from the outside. LPA Lopez inquired how staff obtain a key when coming on shift. The ED said that during staff’s shift change, they should be giving their key to the incoming shift, but recently learned that some staff are keeping their keys and taking them home. The ED said every caregiver should have a key, except when the staff is in training. Nelson said the Med techs also have a set a keys to the resident rooms. On 06/12/2023, LPA Lopez interviewed S5 and said they work the NOC shift and the staff from the prior shift would not provide S5 with a set a keys for the residents’ bedrooms and would say it's not their problem. S5 said when they come on shift, the second person is always late leaving S5 with no access to the resident rooms. On 11/21/2024, LPA Urena reviewed communication between staff members S4 and S5, and the communication revealed that S5 continuously reached out to S4 for the set of keys, since S4 had left the facility premises with the set of keys to the residents’ rooms, consequently S5 could not get into the residents’ rooms. LPA Urena was unable to reach S4 for an interview. At the time of LPA Urena’s initial visit to the facility on 08/06/2024, a FOB key system was in place. The system is an electronic key assigned to every staff member as well to residents, to facilitate entry to their rooms.
Based on interviews and notes review, S5 was left without a set of residents’ room keys to be able to reach the residents as needed for care and supervision in a timely manner. Therefore, the allegation is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted, and a copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 29-AS-20230612083135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/20/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	The deficiency has been cleared due to new FOB key system, which ensures all staff have a key to access residents in their rooms.
	8 9 10 11 12 13 14	Based on interviews, and records review, the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner due to staff lacking room’s keys to access residents, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9