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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802917
Report Date: 09/04/2025
Date Signed: 09/04/2025 03:49:15 PM

Document Has Been Signed on 09/04/2025 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RED ROSES VILLAFACILITY NUMBER:
197802917
ADMINISTRATOR/
DIRECTOR:		BRIAN BUENVIAJEFACILITY TYPE:
740
ADDRESS:13805 E. CREWE STREETTELEPHONE:
(562) 941-3813
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 18CENSUS: 10DATE:
09/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:12 AM
MET WITH:Administrator Brian BuenviajeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 9/04/2025 and was greeted by Assistant Administrator Gloria Gibson. LPA Ramirez identified herself and explained the purpose of the visit. Administrator Brian Buenviaje arrived shortly after to assist. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected nine (9) resident rooms. Resident bedrooms#3 & 4 did not contain the required furniture. LPA Ramirez observed resident room# 3 and 4 were missing nightstand and chairs. Temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and near showers. LPA Ramirez observed non-slip coating in showers. LPA Ramirez observed seated shower chairs. LPA Ramirez observed several missing/broken vertical blinds in room#4,1, and 2. LPA Ramirez observed a shared bathroom in between room#5, to contain black fuzzy spots, spread across the ceilings, walls and corners. LPA Ramirez observed shared bathrooms and resident rooms 1,3,5,2, 4, and 9 to be malodorous and floors were observed to contain black and brown grime. During inspection, LPA Ramirez observed room#3, 4 and 5 signal system was not operational when tested. Administrator Brian Buenviaje arrived shortly after and reset the signal system. LPA Ramirez re-tested the signal system and observed the signal system to be operational. LPA Ramirez observed a cabinet with extra linen inside the "SSG" activities room. Interviews with staff revealed laundry is washed outside and folded outside and clean linen and towels are kept in this cabinet. During inspection and record review, LPA Ramirez did not observe resident room#6, 7 and 8. According to Administrator Buenviaje, resident room#7 was made into a spare activities room and storage area for laundry and linen. Resident room#6 was made into a mini kitchenette and food storage area. Resident room#8 was made into a staff office and medications storage. Review of facility sketch, and plan of operation did not accurately list rooms and usage. SEE 809-C for continued report.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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 13
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917
VISIT DATE: 09/04/2025
NARRATIVE
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Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Residents Rights-Information: LPA Ramirez did not observe the following postings in common areas throughout the facility: Complaint Poster (PUB 475) and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 08/22/2025 and 07/31/2025. LPA Ramirez observed an emergency food supply located in pantry.

Residents with Special Needs: No large bodies of water were observed.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services.

Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for eighteen (18) residents over the age of 59 years old. All may be non-ambulatory.

SEE 809-C for continued narrative.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2025 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/04/2025 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed several missing/broken vertical blinds in room#4 and 1,2, the licensee did not comply with the section cited above in 4 out of 4 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Repair or replacement blinds in resident rooms. LPA Ramirez will return to clear violation.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed shared bathroom in between room#5 and room#1, to contain black fuzzy spots, spread across the ceilings, walls and corners and was malodorous, the licensee did not comply with the section cited above in 10 out of 10 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Staff will clean and sanitze shared bathroom#1,2,3,4, 5 floors. LPA Ramirez will return to clear violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2025 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/04/2025 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87303(g)(1)
Maintenance and Operation
(g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noise shall not reach resident or employee areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cabinet with extra linen is located inside the "SSG" activties room. Interviews with staff revealed laundry is washed outside and folded outside and in this room and clean linen and towels are kept in this cabinet and this room is also used for residents to conduct activities, the licensee did not comply with the section cited above in 10 out of 10 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Licensee will draft plan on how the facility plans to comply with above regulation. LPA Ramirez will return to ensure plan was implemented.
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed resident room# 3 and 4 were missing night stand and chairs, the licensee did not comply with the section cited above in 4 out of 10 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Licensee will draft plan on how the facility will comply with above regulation. LPA Ramirez will return to ensure plan was implemented.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 09/04/2025 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/04/2025 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez did not observe posting, the licensee did not comply with the section cited above in 10 out of 10 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Licensee will draft plan on how the facility plans to comply with above regulation. LPA Ramirez will return to ensure plan was implemented.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 09/04/2025 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/04/2025 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed two (2) out of six (6) reappraisals were not updated once every 12 months or as necessary, even after residents had significant updates on their medical assessments.the licensee did not comply with the section cited above in 2 out of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Licensee will draft plan on how the facility plans to comply with above regulation. LPA Ramirez will return to ensure plan was implemented.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2025 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/04/2025 at 03:10 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(A)(B)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions, of the following:(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used. (B)The grounds showing buildings & recreation area and other space used by the residents. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the facility converted resident rooms 6,7,& 8 for other uses and did not update thier plan of operation, the licensee did not comply with the section cited above in 10 out of 10 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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2
3
4
Licensee will draft plan on how the facility will comply with above regulation. LPA Ramirez will return to ensure plan in implemented.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RED ROSES VILLA
FACILITY NUMBER: 197802917
VISIT DATE: 09/04/2025
NARRATIVE
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Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, and Resident Rights were observed. LPA Ramirez observed two (2) out of six (6) reappraisals were not updated once every 12 months or as necessary, even after residents had significant updates on their medical assessments.

Due to time constraints, LPA Ramirez will return to complete annual inspection. Seven (7) violations were cited and one (1) Technical Advisory was issued. Exit interview was conducted. A copy of this report was provided via email.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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