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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750212
Report Date: 06/16/2026
Date Signed: 06/16/2026 04:12:27 PM

Document Has Been Signed on 06/16/2026 04:12 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:LAUNCH PAD LEARNING PMDFACILITY NUMBER:
197750212
ADMINISTRATOR/
DIRECTOR:		TELMA ROJASFACILITY TYPE:
860
ADDRESS:3035 EAST AVE. STELEPHONE:
(661) 533-3910
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 134TOTAL ENROLLED CHILDREN: 134CENSUS: 56DATE:
06/16/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Telma Rojas, DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On June 16, 2026, Licensing Program Analyst (LPA) Crystal Ali conducted an unannounced annual random inspection. LPA met with Telma Rojas, Director. LPA disclosed the purpose of the inspection to the Director. The facility's hours are Monday through Friday, 5:30am to 7:00pm. Present during today’s inspection were 56 (7 infants, 14 toddlers, 35 preschool) and 13 teachers.

Staffing Ratio and Capacity: Facility maintains an adequate teacher-child ratio. Care and supervision were evaluated and determined basic needs of children are appropriate and are being met. LPA observed sign in/out sheets (app Procare), LIC 9040, and LIC 500. Incidental Medical Services (IMS) were discussed, and Director confirmed that there are two children who fit the IMS program. LPA informed Director that IMS plan needs to be made for the two children and LPA will provide information from today’s visit to assist Director to complete IMS plan. There is a waiver on file for infant play area. LPA observed cameras in common areas to assist with supervision.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2026
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 06/16/2026 04:12 PM - It Cannot Be Edited


Created By: Crystal Ali On 06/16/2026 at 02:37 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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(n)
Fixtures, Furniture, Equipment and Supplies
(n) Furniture and equipment shall be maintained in good condition, free of sharp, loose or pointed parts.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in the building physical plant having rust in bathroom #2 (one toilet and both sinks), cabinet doors missing in Destiny room, rust ring and counter sink loose in Tranquility room, storage room needs to be inacessable to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Director states she will inform maintenance and executive director and place a work order. Director to show proof of correction by email or text messag of photos.
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.
Francisco Pedroza
NAME OF LICENSING PROGRAM MANAGER:
Crystal Ali
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2026 04:12 PM - It Cannot Be Edited


Created By: Crystal Ali On 06/16/2026 at 02:37 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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595(c)(4)

(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.
(2) Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.
(3) The licensee shall require each recipient of the licensing report described in paragraph (1) pertaining to a complaint investigation to sign a statement indicating that he or she has received the document and the date it was received.
(4) The licensee shall keep verification of receipt in each child's file.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in not having LIC 9224 present in child records (3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director states she will have parents complete the forms and place in child file. Director will send proof of completion to LPA by email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Francisco Pedroza
NAME OF LICENSING PROGRAM MANAGER:
Crystal Ali
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


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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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
NARRATIVE
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Physical Plant: The center is a single-story building. It has a 5 classrooms, 5 restrooms, staff breakroom, one staff office, one staff storge, kitchen, and three play yard areas. All furniture and equipment were checked for age appropriateness and good repair. All classrooms are clean and safe. Telephone service was verified. Heating, lighting, and ventilation are adequate. Daily activities schedules were observed in the classroom. Drinking water (large igloo container) is available inside and outside in the form of disposable plastic cups. All containers used for storing solid wastes, including moveable bins, shall have a tight-fitting cover that is kept on; they shall be leakproof and rodent-proof. LPA observed the infant classroom sink needs repair, Bathroom #2 both sinks and one toilet need the rust to be remove, Destiny classroom needs cabinet doors replaced and leak fitted in the wall, and storage room across from kitchen needs to be inaccessible to children. LPA observed a small leak that began today in the Destiny classroom. Maintenance was called and repair is scheduled to be completed on 6/202/6. The leak does not hinder the care and supervision of children. Staff in Destiny classroom and Unity classroom will not be using the one sink in their rooms until repairs have been completed. Children will use the bathroom #1 to wash hands.
Napping: LPA observed naptime for all ages. All children had the proper napping materials and safe sleep is being followed. Staff clean napping materials weekly or more if a child is ill. Washer and dryer is located in a room separate from other classrooms locked.
Kitchen: The facility has a fully functional kitchen area with a locked door. The kitchen has a microwave, refrigerator, freezer, and stove. Allergy list are posted in each classroom and in the kitchen. Director states there are two children that have food allergies. Menus are posted at least one week in advance and made available for review by the parents.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
NARRATIVE
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 All kitchen areas/food preparation areas, and storage areas are kept clean and free of litter, rubbish, rodents, and other vermin. Storage containers for solid waste, including movable bins, shall have tight-fitting covers kept on and in good repair. The facility provides breakfast, lunch, and snacks daily. Chemicals and cleaning solutions are kept separate from the food in the kitchen inaccessible to children.
Bathroom: LPA observed the daycare bathrooms toilets flushed properly and sinks reachable by the children. Staff restroom is in the front of the facility. Each restroom has adequate toilet paper, hand soap, and paper towels available. Restrooms are cleaned, restocked with toiletries and sanitized by Janitor.
Medication: Children are inspected for illnesses and an overall wellness check. A review of medication policy indicated that prescription medication is administered only with the parent’s permission. The teacher and other administration staff administer medication and document the dosage, date, and time on a log. Medication is in the first aid kit backpack on top of cabinet in the classroom. Medication is labeled correctly and stored in its original container. Medication is kept at the center until the expiration date and sent home with the parent for disposal. A review of medication policy indicated that prescription medication is administered only with the parent’s written permission. Required doctor note to pass out medication to the children. Medication is labeled correctly and stored in its original container. Currently two children are on medication as need due to food allergies. Isolation area is in the staff office at the front of the facility. The child will be supervised by the staff until the parent arrives to pick them up.
Fire extinguisher: Fire/earthquake drills are current and completed every 6 months. Disaster drill completed on 4/20/26. A fire extinguisher is in the green located at each entrance of building (service last service 2/26/26), inaccessible to children mounted on the wall. Smoke detector and carbon monoxide detector are on the premises and in compliance with fire marshal standards.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
NARRATIVE
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Director informed LPA that she is unaware of when the last time fire marshall came to the facility was in 2/26/26. The first aid kit was checked and contained all necessary items, including a manual, sterile dressings, bandages, adhesive tape, scissors, tweezers, a thermometer, and antiseptic solution. LPA observed a complete first aid kit located in the front office and small first aid kits in each classroom on the wall next to exit inaccessible to children.
Transportation: The facility does not provide transportation for the children.
Lead Testing/Drinking Water: Lead water testing result completed 9/24/25, there are no concerns. Lead testing results are posted on the parent board.
Outdoor Activity Space: The outdoor play area was inspected and observed to be free of hazards, loose, or sharp objects. Equipment was inspected for safety, cushioning material, good repair and age appropriateness. There are three play areas. LPA observed tricycle track, several tricycles, two large play equipment, and shaded apply area, and one large shed (locked). There is a pool in the preschool play yard fully gated, 12ft hook, life ring, and water alarm present. LPA observed alarms for the gate and the water alarm. The pool area is only for 9 people at a time. LPA observed the pool shower water to be shut off and not usable for anyone. Director states that they have one staff (certified in lifeguard/water safety) that is in charge of swim lessons that take place once a week. LPA observed pool logs, however, they were not logged daily. Pool logs start on 6/2/26. Pool logs should have begun on 8/5/26 when children started attending the facility. Technical violation was issued.
Records/Documentation: LPA reviewed with facility representative the LIC 125, records to be maintained at the facility, for children records (6), staff records (10), and parent board. LPA observed and reviewed all staff records are in compliance. LPA observed children records to not be incompliance. Children records are missing LIC 9224 from Type A received on 5/19/26. LPA observed on parent board all required documents.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
NARRATIVE
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Deficiencies cited: Two Type B deficiencies cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.

A notice of site visit was given and must remain posted for 30 days. A copy of this report and copy of appeal rights were provided to facility representative.

Exit interview conducted and report was reviewed with the Director, Telma Rojas.

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.

Criminal Record Clearance - Child Care Centers
Facility representative 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.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
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Lead Testing – Child Care Centers (CCC)
CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES:
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 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.
Safe Sleep - Child Care Centers
LPA discussed the safe sleep regulations with facility representative 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 facility representative 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) - Child Care Centers
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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:
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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: LAUNCH PAD LEARNING PMD
FACILITY NUMBER: 197750212
VISIT DATE: 06/16/2026
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Commonly Asked Questions about Child Care
Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
PIN 22-05-CCP
MyChildCarePlan.org – Child Care Centers
Facility representative 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.
Subscribe to CCLD important information - Child Care Centers
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-carelicensing/
subscribe and select the Child Care option to receive email communication.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
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