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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750150
Report Date: 04/13/2026
Date Signed: 04/13/2026 04:14:54 PM

Document Has Been Signed on 04/13/2026 04:14 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:ARK ACADEMYFACILITY NUMBER:
197750150
ADMINISTRATOR/
DIRECTOR:		VONDA PERRYFACILITY TYPE:
830
ADDRESS:1146 COMMERCE CENTER DRIVETELEPHONE:
(661) 504-4034
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
04/13/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Vonda Perry, DirectorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On Monday, April 13, 2026, Licensing Program Analysts (LPAs) Mayra Rivera and Sara Rajapakse conducted an unannounced annual inspection and met with Director Vonda Perry, who guided LPAs on a tour of the facility. Annual fee is current.

This is a infant program that serves children ages 0 -2 years. This program operates Monday to Saturday 5:00 am to 8:00 pm. Sign in and out takes place at the main entrance area. Present staff are fingerprinted cleared. Present staff do not have a current pediatric first aid/CPR certification. LPA informed Director, at least one person present must have a current pediatric first aid/CPR certificate.



LPAs entered the infant classrooms. LPA Rivera observed 4 infants with staff #1 present providing care and supervision. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA Rivera did not observe cleaning supplies in the classroom. Director stated the cleaning supplies are stored in the kitchen off-limit area. LPAs observed child #2 napping inside crib face down. LPAs v observed the cribs to be free from bumper pads, pillows, toys, blankets, hanging above items. LPA Rivera observed a diaper genie. LPA observed the diapering changing table to be arm’s length to the handwashing sink with a vinyl diapering mat. Per Director, soiled clothing is not rinsed in the sink. It is placed in a plastic bag and the vinyl mat is disinfected with alcohol and water. LPA Rajapakse observed hooks for children’s personal bags to hang. LPA Rajapakse observed infant bottles not to be labeled with children names and stored in their diaper bags. LPA Rivera informed Director bottles and food brought from home shall be labeled with the child's name and properly stored or refrigerated.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
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 04/13/2026 04:14 PM - It Cannot Be Edited


Created By: Mayra Rivera On 04/13/2026 at 02:17 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: ARK ACADEMY
FACILITY NUMBER: 197750150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101429(a)(2)(B)(3)(a)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: (3) Infants up to 12 months of age who are sleeping in a position other than on their back. (a) If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, staff shall return the infant to their back for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in child #2 napping face down and LIC 9227 not completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2026
Plan of Correction
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Director stated will provided parent LIC 9227 Individual Safe Sleep Plant to complete and for all infants under 12 months and submit proof to LPA Rivera by due date.
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:
Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2026 04:14 PM - It Cannot Be Edited


Created By: Mayra Rivera On 04/13/2026 at 02:17 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: ARK ACADEMY
FACILITY NUMBER: 197750150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having Infant Needs and Services Plan for all infants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2026
Plan of Correction
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Director stated will provide parents Needs and Services Plan for parents to complete and submit to LPA Rivea by due date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in child #2, child #3, and child #4 not having a medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2026
Plan of Correction
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Director stated will provide parents LIC 701 Physician's Report tor parents and informed it is a requirement and submit proof to LPA Rivera by due date.
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: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 04/13/2026
NARRATIVE
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Heating, lighting and ventilation were evaluated by LPA Rivera. LPA observed central AC /heater and vents located on the ceiling. LPA observed the thermostat located in classroom and the temperature to be at 75. Carbon monoxide located in the preschool classroom was tested by LPA Rivera. LPA Rivera heard the sound, and it is operable. The last emergency drill was conducted on 3/12/26.

First aid kits supplies are kept inside the classrooms and LPA Rivera observed the kits to be complete. During this visit, director stated currently has no children with prescribed medication or on medication. LPA Rivera asked if there were any poisons, firearms, weapons or bodies of water. The director stated there’s no firearms, weapons, no poisons nor bodies of water. LPAs did not observe firearms or weapons, poisons, nor bodies of water. Director stated the ill isolation area children’s alternate rooms. If they are using the yellow room, then the blue room is utilized. Lead testing was conducted on 07/22/25 and no lead exceedance.

LPA Rivera entered the outdoor play area. LPA Rivera observed the playground to be fenced all around and the gate that leads to the parking lot, closed and observed the gate to have a push bar. LPA Rivera 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 Rivera observed play structure equipment to be age appropriate and climbing equipment, are cushioned with artificial turf that may absorb a fall. For shade, LPA Rivera observed one gazebo.

This program provides snacks and lunch for the toddlers and parents provide the formula for infants. Meals and snacks are prepared onsite. For water drinking, LPA Rivera observed water pitchers, bottles, and sippy cups in the classrooms. LPA observed the food preparation area to be clean and free of litter, rubbish, rodents, and/or any other vermin and storage containers for solid waste, including movable bins with tight-fitting covers that are kept on, and in good repair. The facility was observed to be free of flies, other insects, and rodents.

The following documents were posted in a prominent, publicly area front lobby: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and PUB 269 Child Passenger System Poster, and Daily Schedule.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 04/13/2026
NARRATIVE
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LPA Rivera reviewed the children’s roster, children’s files, staff files, 15-minute sleep logs, and sign in/out sheets and observed 4 signed in signatures. LPA Rivera observed the children files to be incomplete (listed on LIC 857). LPA reviewed child #2 file for LIC 9227, and LPA Rivera observed LIC 9227 not in the file and per director have been informing parent to complete. LPA did not observe Needs and Services Plans for all infants. Director stated was not aware of the Needs and Services Plan for infants. LPA observed child #2, child #3, and child #4 missing LIC 701 Physician’s Report. Director stated was not aware of children not having the form completed by a Physician.

LPA Rivera observed Director Vonda Perry Preventative Health and Safety with nutrition and lead component dated 01/08/2023. LPA observed an exemption for measles and pertussis. Director has completed the child abuse mandated reporter certificate dated 06/17/2025. Director was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com



The following was also discussed with Director:

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. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.



4. LIC 125 Entrance Checklist provided, and LPA informed that forms, regulations and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 9 of 12
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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 04/13/2026
NARRATIVE
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5. Pediatric First Aid and CPR: At least one person trained in Pediatric First Aid and CPR and EMSA approved must be present.

6. Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7. Qualifications: Educational background, training, and/or experience for each staff present must be available for review.

8. Immunization Requirements: 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 or influenza declination

9. Children’s Records: must be available for review; including but not limited to, the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

10. Staff Records: must be available for review; background clearance, LIC 503 Health Screening report, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, Staff Qualifications, LIC 9050 Employee Rights, LIC 501 Personnel Record, Mandated Child Abuse Certification, MMR, TDAP, TB, influenza or influenza declination.

11. Isolation- When a child is ill, he/she shall be separated from other children, and remain separated.

12. 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.

13. 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 624).

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

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 04/13/2026
NARRATIVE
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15. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and carbon monoxide detectors should be checked, and batteries replaced as needed.

Director Vonda Perry was reminded that all adults 18 and over, 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 Child Care Center. 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.



For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-carecenters/.

Director Vonda Perry 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.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 11 of 12
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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 04/13/2026
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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.

The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Title 22. One Type A deficiency is being issued today for regulation 101429(a)(2)(B)(3)(a)- (B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: (3) Infants up to 12 months of age who are sleeping in a position other than on their back. (a) If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, staff shall return the infant to their back for sleeping.

The deficiencies listed on the following page were observed by LPA Rivera and are being cited in accordance with California Code of Regulations Title 22 or Health and Safety code. Two Type B deficiencies are being issued today for regulation 101419.2(a)- (a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant. 101220(a)- (a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

Deficiencies that are being cited need to be cleared to protect the children’s health & safety. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return and any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report was reviewed with Director Vonda Perry.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
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