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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609554
Report Date: 05/20/2022
Date Signed: 05/23/2022 10:09:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220511151945
FACILITY NAME:SUNSHINE RESIDENTIAL HOME WOODLEYFACILITY NUMBER:
197609554
ADMINISTRATOR:JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:10534 WOODLEY AVENUETELEPHONE:
(818) 274-1809
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Laila KulunguTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility is infested with roaches
Facility is not kept clean
Resident's not provided a clean and comfortable mattress
Resident was not provided a flame retardant mattress cover
Facility did not have an adequate supply of comforters and linens for each resident
Medications are inadequately stored and accessible to residents
Hazardous items left accessible to residents
Facility is in disrepair
Staff are providing expired food to residents

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home at 8:45am. The LPA was greeted by facility staff and the LPA explained the reason for the visit. The Licensee was called and arrived a short while after.

Allegation 1. Facility is infested with roaches
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that they have been having a cockroach problem and that the facility was just treated for this. At 9:30 am, the LPA was able to interview residents who also confirmed that they have seen cockroaches in their rooms and in the kitchen. At about 10am, the Licensee was interviewed and also confirmed that they have had a problem with cockroaches, but the problem has been treated. Based on interviews with staff, residents, and the licensee this allegation is deemed to be Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
VISIT DATE: 05/20/2022
NARRATIVE
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Allegation 2. Facility is not kept clean
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff confirmed that on this date, the refrigerator was dirty from spills and other food debris. An interview conducted with the licensee also confirmed this. The staff and the licensee showed the refrigerator to the LPA and has since been cleaned. Based on confirmation from staff and the licensee that the refrigerator was not clean on 5/10/2022, this allegation is deemed Substantiated.

Allegation 3. Resident's not provided a clean and comfortable mattress
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, Resident 1's (R1) box spring was observed to be broken. R2's mattress was also observed to be stained and in need of replacement. On todays visit LPA observed the box spring and the mattress to have been replaced. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 4. Resident was not provided a flame retardant mattress cover
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, R3 and R4's box spring and mattress were observed in the original plastic wrappings. The licensee confirmed that he has since removed the plastic covering and has replaced it with fire retardant protectors. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 5. Facility did not have an adequate supply of comforters and linens for each resident
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, it was observed to not have enough comforters for all residents. The licensee provided the LPA with receipts for recently purchased comforters since then. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.
Cont. on LIC 9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
VISIT DATE: 05/20/2022
NARRATIVE
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Allegation 6. Medications are inadequately stored and accessible to residents
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, staff had left her eye drops on the counter and accessible to the residents. On today's visit, all medications were observed to be locked in a the medication room. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 7. Hazardous items left accessible to residents
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, chemicals were left in an unlocked cupboard under the sink and accessible to residents. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 8. Facility is in disrepair
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, the sitting room was observed to have a couch and a chair to be in disrepair. The curtains in the sitting room were torn and in disrepair. Paint was also observed to be chipping in multiple areas. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 9. Staff are providing expired food to residents
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, that there were multiple expired foods in the refrigerator and in the dry food pantry. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Exit interview conducted, deficiencies cited and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220511151945

FACILITY NAME:SUNSHINE RESIDENTIAL HOME WOODLEYFACILITY NUMBER:
197609554
ADMINISTRATOR:JOSE, OYINLOYE AUSTINEFACILITY TYPE:
735
ADDRESS:10534 WOODLEY AVENUETELEPHONE:
(818) 274-1809
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility thermostat is locked prohibiting residents from adjusting individual thermostatic controls.
Administrator did not maintain staff records in the facility
Administrator did not maintain resident records in the facility
Facility emergency evacuation plan is expired
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home at 8:45am. The LPA was greeted by facility staff and the LPA explained the reason for the visit. The Licensee was called and arrived a short while after.

Allegation 1. Facility thermostat is locked prohibiting residents from adjusting individual thermostatic controls.
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. Staff and the licensee both confirmed that on this date, they had locked the thermostat and restricted residents access to it. On todays visit, there was no lock on the thermostat observed. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
VISIT DATE: 05/20/2022
NARRATIVE
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Allegation 2. Administrator did not maintain staff records in the facility
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. The licensee confirmed that on this date, he was not available and was unable to unlock the file room. The licensee has since provided staff with access to the file room and created digital files. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 3. Administrator did not maintain resident records in the facility
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. The licensee confirmed that on this date, he was not available and was unable to unlock the file room. The licensee has since provided staff with access to the file room and created digital files. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Allegation 4. Facility emergency evacuation plan is expired
LPA was able to interview staff, residents and the licensee regarding this allegation. At 9:00 am facility staff stated that on 5/10/2022, the North Los Angeles County Regional Center came to the home to conduct a visit. The licensee confirmed that on this date, the Emergency Disaster Plan form (LIC 6100) was out dated. An updated LIC 6100 was provided to the LPA during todays visit. Based on confirmation from staff and the licensee that the observations made on 5/10/2022 were accurate, this allegation is deemed Substantiated.

Exit interview conducted, deficiencies cited and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
80088(a)(2)
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80088(a)(2) Furniture, Fixtures, Equipment, and Supplies
Nothing in this section shall prohibit clients from adjusting individual thermostatic controls. This require was not met as evidenced by: Base on licensee admission, the licensee did not
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POC cleared before visit.
Lock on thermostat was not present during visit.
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allow access to the thermostat by placing a lock over it, which is a potential health and safety risk to the residents in care
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Type B
05/20/2022
Section Cited
CCR
87412(f)
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All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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POC cleared before visit.
Staff now have access to the file room and all files are now digital and available for review
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This requirement is not met as evidenced by: Based on Licensee admission, the licensee did not allow staff access to facility fillies, which poses a potential risk to the 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
HSC
1569.695(c)
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1569.695(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide...
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POC cleared before visit.

An updated disaster plan was given to LPA during visit.
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This requirement is not met as evidenced by:

Based on licensee admission, the licensee did not ensure that emergency disaster drill records were updated, which poses a potential 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. Licensees shall take measures to keep the facility free of flies and other insects.

. This requirement is not met as evidenced by: Based on licensees admission, cockroaches were observed throughout the
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POC cleared before visit. A copy of the extermination receipt was provided to the LPA.
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home, which is a potential health and safety risk to the residents in care.
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Type B
05/20/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidenced by : Based on the lisensee admission, the licensee did not ensure the refidgerator was
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The refrigerator had been cleaned and the curtains replaced. A receipt from a handyman was provided as POC

Cleared before visit.
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cleaned and the couch and curtains were not in good repair which poseses a potential health and safety risk to the 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
80087(g)
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80087 Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Chemicals were immediately removed and the cabinet was locked. Staff put eye drops away. Licensee provided an in-service to staff.

Cleared before visit.
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Based on licensee admission, the licensee did not ensure that chemicals and staff eye drops were inaccessible to residents, which posses a health and safety risk to the residents in care.
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Type B
05/20/2022
Section Cited
CCR
85088(c)(1)
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85088(c)(1) Fixtures, Furniture, Equipment and Supplies. The licensee shall ensure that each client has an individual bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement was not met as evidenced by: Based on the licensee admission, the
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A receipt for the new box spring, comforters and linen and flame retardant mattress cover was provided as POC

Cleared before visit.
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licensee did not ensure a resident had a functional box spring, proper linen and a flame retardant mattress cover, which poses a potential risk to the 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 31-AS-20220511151945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSHINE RESIDENTIAL HOME WOODLEY
FACILITY NUMBER: 197609554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
80076(a)(7)
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80076 Food Service
(a)In facilities providing meals to clients, the following shall apply: (7)......All foods shall be selected, ....stored, prepared and served so as to be free from contamination and spoilage ... This requirement is not met as evidenced by; Based the admission of the
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All spoiled food was removed and the fridge was cleaned.

POC cleared before the visit
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licensee, the lisensee did not ensure that spoiled food was removed from the refrigerator or the pantry which poses a potential risk to the health and safety of the 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 10 of 10