197701042-3-23-2026-12-CC-EGAA-DPXQYC-20260102113454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197701042
Report Date: 01/02/2026
Date Signed: 03/23/2026 12:05:51 PM

Document Has Been Signed on 03/23/2026 12:05 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	SARGSYAN FAMILY CHILD CARE		FACILITY NUMBER:	197701042
ADMINISTRATOR/ DIRECTOR:	LYUDMILA SARGSYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 213-0992
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	01/02/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Lyudmila Sargsyan, Applicant		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On Friday, January 2, 2026, at 9:30 a.m., Licensing Program Analyst (LPA) Evelyn Garcia conducted an announced pre-licensing inspection and met with applicant Lyudmila Sargsyan, who guided LPA Garcia on a tour of the facility. The applicant is requesting a large family childcare license. Family members residing in the home include the applicant, husband and 2 adult children. All persons living in the home have been discussed with applicant and are fingerprinted and cleared. Operating hours will be Monday- Saturday 8:00 am to 8:00 p.m. and care for children ages 2 – 13 years. This facility is a single-story home. The property is a rental and the home consists of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, and attached garage (no access from within the home), front yard, and back yard fenced. There is current construction for an ADU that has a separate address (7427 Cleon Street) and will not be used for daycare purposes and has no access the applicants property. There are no pools or bodies of water on either of the premises.
Areas off limits to children include- 3 bedrooms #1-#3, kitchen, bathroom (toward back of home), back yard, attached garage, and ADU property.

Areas accessible to children include- Bedroom near the entrance of home (main daycare area), bathroom (hallway closest to daycare area), living room, dining room, front yard fenced.

LPA Garcia inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Garcia observed central heating and air conditioning and vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. This property is a rental and the applicant provided proof of the rental agreement. The main daycare area will be in bedroom #4 which is the bedroom closest to the front entrance of the home. LPA observed cots stored in the daycare room, applicant stated the children will be using cots and will utilize the main daycare room for naptime.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

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

LIC809 (FAS) - (06/04)

Page: 1 of 8

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)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Kitchen: The kitchen will be off limits to the children. Applicant will be installing a safety gate on the entry way from the dining room to the kitchen to prevent access to the children. LPA Garcia observed cleaning compounds stored in a cabinet located under the kitchen sink and secured with a safety lock. LPA did observe knives and sharp objects stored in kitchen drawers, made inaccessible to the children with safety latches. For water drinking, applicant stated she will use a filtered water dispenser and children will use disposable cups and re-fill as needed. The applicant stated she will prepare meals for the children and possibly use a food program in the future. Meals provided will be breakfast, lunch, p.m. snacks. LPA informed applicant food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

Bathroom: LPA Garcia entered the restroom that will be utilized by the daycare children which is located in the hallway closest to the daycare room. LPA observed the toilets, hand washing sinks, hand soap and LPA observed the bathrooms to not have any hazardous materials accessible to the children. Hazardous materials are secured under the sink cabinet and secured with a safety latch. LPA reminded applicant that Shampoos, conditioners, body washes, etc. need to be inaccessible to the children while they are in care. The restrooms were observed to be in good, clean operable condition.

LPA Garcia asked the applicant if there are any pets, poisons, firearms, weapons, or bodies of water. Applicant stated she has 1 small dog, no poisons, no firearms, no weapons, nor bodies of water on premises. LPA did not observe the dog, poisons, firearms, weapons, nor bodies of water. Applicant was advised 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 must be stored separately. Applicant was also advised that it was recommended to keep the dog isolated from the daycare children.

LPA Garcia observed the required 3A40BC fire extinguisher located in the kitchen secured on a wall mount, valve on the green area indicating fully charged and purchase receipt dated 10/12/25. LPA informed applicant that the fire extinguisher needs to be serviced annually or purchase a new one within a year and tape the purchase receipt. LPA observed a dual carbon monoxide and smoke detector located in the hallway ceiling. Applicant tested the dual carbon monoxide/ smoke alarm. LPA Garcia heard the sounds and is operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the kitchen shelf which is inaccessible to the children. For ill isolation, applicant stated the dining room will be utilized, and keep the children separate until the children’s parents can pick them up.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Outdoor: LPA Garcia inspected the play outdoor (front yard) area that will be used by children for safety, comfort, and cleanliness. The area that will be utilized by the children is enclosed by rolling iron gate that measures over 5” tall and has an electronic lock. Applicant states there will only be 1 car in the driveway and will not be moved while children are present. Applicant also stated she will install sunshade sails when the weather requires, to provide shade for the children. On the left side of the home, there is a white vinyl gate that leads to the yard, it is locked with key and lock and prevents access to the applicants back yard. On the right side of the home, there is currently a mesh fence that prevents access to the construction of the ADU on the property. Applicant states there is going to be a fence that divides her property from the ADU property and will not have access to the ADU property or vice versa. The applicant will also place a safety gate before the fence that divides the property to prevent children from accessing electrical panels. Construction is scheduled to end in March. The front yard surface of the outdoor activity space is maintained in a safe condition (concrete, grass) and is free of hazards. LPA Garcia also inspected the back yard. The backyard, however, will not be utilized by the daycare children and will be off-limits and inaccessible to the children.

LPA observed applicant American Red Cross Pediatric First Aid/ CPR certification dated 8/16/25, and Health and Safety certification dated 8/9/25, and applicant has proof of immunization against Pertussis, MMR, TB and Influenza. Applicant has completed the mandated reporter (AB 1207) training dated 8/16/25. Applicant was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA informed Applicant of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months and 15-minute sleep check documentation for infants 0-24 months. LPA provided the LIC 9227 Individual Infant Sleeping Plan and Safe Sleep Log form.

During the inspection, applicant posted the required postings LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, LIC 999 Facility sketch, and child car seat law poster. LPA informed applicant, the required posting need to be posted in the area where parent can view the information.

The following was also discussed with the applicant:

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.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

3. In the absence of the applicant 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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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). Mandated reporter requirements were reviewed and explained.

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

10. Smoking is prohibited in the family childcare home.

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

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

12. 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 applicant and all adults working with children have proof of immunizations.

13. 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.

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

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

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

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

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

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 Childcare 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.

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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA Garcia explained in detailed to applicant LIC 9221 Parent Consent for Administration of Medications and medication chart, LIC 9040 Childcare Facility Roster, LIC 624 Unusual Incident Report, LIC 9227 Individual Infant Sleeping Plan, Safe sleep practices, safe sleep log, the California Car Seat Law Changes (effective February 2018, and Sudden Infant Death Syndrome (SIDS). Entrance Checklist was provided to the applicant.

LPA discussed the safe sleep regulations with applicant and discussed the Childcare 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 applicant 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.

On this date, 10/29/25, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA reviewed with [applicant, licensee, or facility representative] the LIC 311D, Forms/Records to Keep in your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 7 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SARGSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197701042
	VISIT DATE: 01/02/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Corrections needed: Safety gate to prevent access to kitchen, and safety gate preventing access to electrical panels and construction of ADU.

A notice of site visit was given to applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview was conducted and report was reviewed with applicant, Lyudmila Sargsyan.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026

LIC809 (FAS) - (06/04)

Page: 8 of 8