197700804-6-18-2026-12-CC-MRIA-DV6TTM-20260618150058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700804
Report Date: 06/18/2026
Date Signed: 06/18/2026 03:01:32 PM

Document Has Been Signed on 06/18/2026 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	MARGARYAN FAMILY CHILD CARE		FACILITY NUMBER:	197700804
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 10	CENSUS: 7	DATE:	06/18/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:03 PM
MET WITH:	Shushanik Margaryan, Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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On Thursday, June 18, 2026, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and capacity increase. LPA met with licensee Shushanik Margaryan who granted access and guided LPA Rivera on a tour of the facility.

Fire clearance has been granted as of June 5, 2026, for 14 children and garage is to be used for storage use only at this time. Garage is under construction to be permitted as a habitable space at a later time. The licensee was advised of the following conditions for operating at full capacity: A maximum of 14 children, including no more than 3 infants, with 2 school-age children enrolled or a maximum of 12 children, with no more than 4 infants. A qualified assistant must be present when more than 8 children are in care.

Operating hours are Monday to Sunday from 6:00 am to 9:00 pm and care for children ages 0 to 13 years old. All adults residing in the home has been discussed with licensee and are cleared. LPA observed 2 school-age children and 5 preschoolers. LPA observed facility to be within ratio. Annual fee is current.

This facility is a two-story home that consists of 4 bedrooms, 2.5 bathrooms, kitchen, living, front and backyard fenced.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

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

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 06/18/2026 03:01 PM - It Cannot Be Edited

Created By: Mayra Rivera On 06/18/2026 at 02:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in not renewing child abuse mandated reported certificate expired September 11, 2025 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2026
	Plan of Correction
1 2 3 4	Licensee stated will completed the child abuse mandated reporting training and submit to LPA Rivera by due date. Licensee stated will place notes on her phone calendar to remind herself.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lady King
NAME OF LICENSING PROGRAM MANAGER:

	Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

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LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC/heater, and the vents located on the ceiling. LPA did not observe a fireplace or a wall heater. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed a play yard to be occupied with toys. Licensee, stated during this visit, no children under 24 months enrolled. LPA informed play yard or crib must have a mattress with a fitted sheet and free from bumper pads, pillows, blankets, hanging items and no swaddling or attached pacifier.

LPA Rivera observed cleaning compounds items, knives and sharp objects stored underneath kitchen sink with a childproof lock making it inaccessible for children to open. For water drinking, LPA observed a water dispenser and sippy cups. Licensee stated she provides the meals and snacks for the children. LPA informed licensee food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed. LPA did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked licensee if there are any pets, poisons, firearms, weapons, or bodies of water. Licensee stated she has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, weapons, nor bodies of water. Applicant was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

NARRATIVE

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LPA Rivera observed the required 2A10BC fire extinguisher located in the closet near the main entrance with the valve on the green area indicating fully charged and purchased receipt dated June 3, 2026. LPA observed a carbon monoxide detector and smoke alarm located in the living room. Licensee tested the carbon monoxide and heard the sound and observed the green light flashing on the smoke alarm located in the family. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the closet. For ill isolation, licensee stated she utilizes the family room. LPA observed last emergency drill conducted on January 6, 2026.

LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the yard to be gated and observed the side gates to be closed and locked with a self-latch. LPA observed the equipment to be in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA did not observe any climbing equipment. LPA inform if any equipment that has high climbing must have a cushion that can observe a fall.

LPA observed licensee Shushanik Margaryan Emergency Medical Services Authority (EMSA) Pediatric First Aid/ CPR certification dated April 3, 2026, and Health and Safety certification dated 3/24/2024 and licensee has proof of immunization against Pertussis, MMR and Influenza declination. Licensee has completed the child abuse mandated reporter training dated September 11, 2023. LPA informed certification expired on September 11, 2025 and must be renewed every two years. Licensee stated will do it today.

LPA observed the postings License, and Pub 394 Notification of Parents Rights. LPA also reviewed children’s roster, children files. LPA observed the files to be complete.

During this visit a speech therapist arrived to provide services to 3 children. The services were provided in the backyard and temperature to be 77 degrees. Licensee observed and able to hear the interactions.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

NARRATIVE

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LPA Rivera observed the garage permitted construction plans for the Junior Additional Dwelling Unit (JADU) and observed the plan to have a different address by having ½ on the address. LPA informed licensee for the JADU to be used for daycare the licensee must live in the JADU because the address is different by having the ½. LPA informed to speak with the city permit inspector and ask if it is required to add the ½ since the JADU is attached to the kitchen.

The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

NARRATIVE

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5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

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14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

20. LIC 126 Checklist for Family Child Care provided and reviewed.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

NARRATIVE

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Licensee Shushanik Margaryan was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Child Care Centers and Family Child Care Homes LPA discussed the safe sleep regulations with licencee Shushanik Margaryan and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Shushanik Margaryan of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

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

Licensee Shushanik Margaryan, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MARGARYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700804
	VISIT DATE: 06/18/2026

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The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Health and Safety code. One type B deficiency is being issued today for regulation 1596.8662(b)(1)- (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. Please see attached LIC 809-D for citation.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the licensee Shushanik Margaryan.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026

LIC809 (FAS) - (06/04)

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