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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750002
Report Date: 07/14/2025
Date Signed: 07/14/2025 02:58:30 PM

Document Has Been Signed on 07/14/2025 02:58 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:KCE CHAMPIONS LLC @ILEAD-LANCASTERFACILITY NUMBER:
197750002
ADMINISTRATOR/
DIRECTOR:		JESSICA CARRIZALFACILITY TYPE:
840
ADDRESS:254 EAST AVENUE K-4TELEPHONE:
(661) 483-9947
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 100TOTAL ENROLLED CHILDREN: 100CENSUS: 38DATE:
07/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Director Latasha MauldinTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On July 14, 2025, at 10:01 A.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo met one of the front office staff and told the staff that LPA will conduct an unannounced One Year Required inspection for the School Age license. The staff checked on the rooms to see if the director is currently at the facility. The staff came and gave the LPA the phone number of the director.

At 10:08 A.M., LPA called Latasha Mauldin, the director (DR), regarding the conduct of an annual inspection. DR told the LPA that she was not at the facility, and she was at a meeting. DR told the LPA that she will be at the facility by 11:00 A.M.

LPA asked DR if LPA could check the rooms license under CCL DR told the LPA that the Village and the Kindergarten rooms are licensee under the CCL and it was only the Village room that they are currently using. LPA told DR who are the staff inside the Village room. DR stated that Kiana, Jody, and Rihanna are currently in the room. LPA also asked if LPA could do the physical inspection in the room while waiting for the director. DR told the LPA that DR will call Kiana and will assist LPA regarding the inspection.

At 10:24, LPA met Director Mauldin in the Village room. The program is conducted in the Village room, and in the Transitional Kindergarten (TK) room. The school age program also has an outdoor play area. Per Director Mauldin, the Village room is currently being used by children.

This School program is held on the campus of ILead Elementary School in the Multi-purpose room. The hours of operation are Monday to Friday, from 6:30 A.M. - 6:00 P.M. A tour of the facility was conducted. LPA observed a total of 38 school age children in the Village classroom with three staff providing care and
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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 07/14/2025 02:58 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 07/14/2025 at 02:11 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: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #1 to #3 immunization records which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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The director will send copies of the immunization records for staff #1 to #3 to LPA.
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
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #1 and #2 mandated reporter training which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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The director will email copies of staff #1 and #2 mandated reporter training certificates to LPA.
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:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 02:58 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 07/14/2025 at 02:11 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: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #2 and #3 LIC 503 Health Screening, and staff #3 TB clearance which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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The director will email copies of staff #2 and #3 LIC 503 Health Screening, and staff #3 TB clearance to LPA.
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #2 LIC 9052 Employee Rights which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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The director will email a copy of staff #2 LIC 9052 Employee Rights to LPA.
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:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 02:58 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 07/14/2025 at 02:11 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: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(b)(1)
Teacher Qualifications and Duties
(1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement specified in (c)(1) below; or shall have obtained a Child Development Assistant Permit issued by the California Commission on Teacher Credentialing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #3 credentials/school transcripts pertaining to child development which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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The director will email a copy of staff #3 enrollment/registration in child development courses to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002
VISIT DATE: 07/14/2025
NARRATIVE
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supervision. Incidental Medical Services (IMS) was discussed. Licensing fees are current.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, ramps, and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean, cleaning compounds are inaccessible, poisons are locked, furniture/equipment is in good condition and is free of flies, other insects, and rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, children have baskets for personal belongings. There is a working telephone. Electrical outlets were observed to have missing child safety plastic covers. The director was advised to put child safety covers for the outlets. Recalled and or prohibited toys or sleep/play equipment were not observed on the premises. There are no window cords accessible to children.

Trash bins have lids. Drinking water is provided in every classroom and is stored in an orange water jug. Water fountains are also available. Children bring their own bottle/container when drinking. All materials and surfaces are toxic free and are inaccessible. There is no fireplace in the facility. The center has an internal pull-down fire alarm system and 3-A:10-B:C type of fire extinguishers. LPA was not able to check the carbon monoxide device due to the device is located up to the ceiling and it is connected to the fire station. Per Robert Hutson (Maintenance Personnel), the school conducts its own fire and disaster drill. The fire drill was last conducted on June 6, 2025.

Restrooms: LPA inspected the bathrooms and observed a total of 3 toilets and 3 sinks for the two bathrooms. The toilets and sink are in working conditions. LPA observed liquid soap, toilet paper, and paper towels were readily available. A water fountain is observed, and it is located next to the bathroom for the Village room. Water temperature is appropriate. There is an isolation area for children who become ill while in care which is located in the innovation room.



Per Director Mauldin, the facility has one foldable cot that is being used for a child with symptoms of illness. The facility maintains a comfortable temperature at all times, first aid supplies (first aid manual/guide, bandages, scissors, tweezers), sign in/out sheets (manual) available and completed daily. Smoking is
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002
VISIT DATE: 07/14/2025
NARRATIVE
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prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed or stored on premises. There is no body of water on the premises.

Napping: Per Director Mauldin, children do not nap at the facility. LPA did not observe napping cots.

Outdoor: The facility has two playground areas for school-age children. LPA also observed a small soccer area. One of the playgrounds is appropriate for children between 5 to 12 years old. Outdoor play equipment was inspected for health, safety, good repair, and age appropriateness. The area was observed to be free of debris, free from hazard, holes, broken items, debris. The slides have rubberized cushioning material. No bodies of water were observed.

Teacher child ratios were observed, and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.



Health Related Services: According to the director, they were not providing medications to children in care.

Children are inspected for illnesses (wellness policy) as they arrive. Per Director Mauldin, children are visually observed once they arrive at the facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

Food Service: The facility provides lunch to children during the summer school program. The food is prepared and pack by the Fresh Start and it will be delivered at 7:00 A.M. The food is then stored inside the refrigerators and served during lunchtime.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002
VISIT DATE: 07/14/2025
NARRATIVE
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Staff/Personnel Records: Director (qualified) and staff qualifications were reviewed. Immunization, TB clearance, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were reviewed and some documents are not in file. Staff #2 do not have units in child development. Staff #1 has 14 units in child development and staff #3 have 9 units in ECE. Per Director Mauldin, staff #2 will enroll/register in child development courses.

Facility Records: Roster, fire/disaster drills log was last completed on March 3, 2025, CPR/First Aid, and mandated report training were reviewed. Staff # 1 and 2 do not have current mandated reporter training. Staff #1 to #3 have current CPR/First Aid training on file.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty. The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 394), emergency disaster plan, earthquake preparedness checklist.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. Staff #1 and #2 were advice to take online mandated reporter training at www.mandatedreporterca.com

Sign in and out sheets were reviewed. The parent board was reviewed and has all the required forms posted. Fire/earthquake drills current.

Director was advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of the family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: KCE CHAMPIONS LLC @ILEAD-LANCASTER
FACILITY NUMBER: 197750002
VISIT DATE: 07/14/2025
NARRATIVE
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The director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Director shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

Type B deficiencies were cited during this inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.



Exit interview conducted and a copy of this report, Notice of Site Visit, and appeal rights were provided to Director Latasha Mauldin.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
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