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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004486
Report Date: 09/11/2025
Date Signed: 09/11/2025 03:19:38 PM

Document Has Been Signed on 09/11/2025 03:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MONTESSORI ACADEMYFACILITY NUMBER:
198004486
ADMINISTRATOR/
DIRECTOR:		BIBILE, NIRANJALAFACILITY TYPE:
850
ADDRESS:1920 W. GLENOAKS BOULEVARDTELEPHONE:
(818) 841-9096
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 85TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
09/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Niranjala Bibile, Licensee/DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced Annual/Random inspection on 09/11/25. LPA arrived to the facility at 11:40 AM. LPA met with Niranjala Biblie, director who guided LPA on a tour of the facility. This is a preschool program located in the St Matthew's Lutheran Church property. The preschool program operates Monday – Friday from 6:30 AM – 6:00 PM.

All areas identified on the Facility Sketch were inspected. Upon arrival, the following staff were present during this inspection: LPA observed 7 children were playing in the classroom with one staff .Per director, currently there is only one classroom with 8 enrolled children. The facility was observed to be within the license capacity and limitations. Staff names were recorded. The following was observed during the tour of the facility:

PHYSICAL PLANT: LPA observed the facility to be clean, safe, sanitary and in good repair. Per director, cleaning person cleans the facility daily after hours. Furniture and equipment were inspected for age appropriateness and good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubbies to store their belongings in each classroom. Parents take Linens home each week on Friday or as needed and return them on Monday. Napping equipment (cots) were observed to be stored in the classroom. Age-appropriate sinks and toilets were inspected for availability and good repair in all restrooms. General sanitation was observed. Availability of indoor drinking water was observed in the classroom. Per director, children use their water bottles in the classroom. LPA observed children water bottles and water pitcher in the classroom.


REPORT CONTINUES ON NEXT PAGE 1 OF 4
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486
VISIT DATE: 09/11/2025
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Disinfectants, cleaning solutions, medication, and other items that are dangerous to children, were inaccessible to children. Per director, there is one insect killer in the office cabinet out of reach of children. Director tested the carbon monoxide detectors in the kitchen. It sounded off the alarms and heard by LPA to be functional. LPA observed required posting information was posted in the hallway of entrance.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal.

Outdoor playground equipment is in a safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. However, LPA observed outdoor play structure area is full of leaves, dust and spider webs and it needs to be cleaned to be safe and sanitary for children use. Per director, due to summer heat children have not been outside on the play structure area during summer. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with cushioning material that absorbs a fall; climbing apparatuses are single level only. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. Per director, children use their water bottles during outdoor playtime. LPA advised that no children shall be left without the supervision of a teacher at any time.

Per director, facility front yard, grass area, will not be used for children play anymore, and it will be used only for commute.

The Director states that there are no bodies of water on the premises and LPA did not observe any bodies of water during this inspection. There is a decorative wall water fountain in the front yard. The director states there are no weapons or firearms on the premises.

FACILITY RECORDS

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.


REPORT CONTINUES ON NEXT PAGE 2 OF 4
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486
VISIT DATE: 09/11/2025
NARRATIVE
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Eight Children’s Records were reviewed for completeness; Inspection of required forms was made and documented on the LIC 857. 1 out of 8 reviewed files, child#2 did not have Physician Report on file.

There is not at least one person trained in CPR and Pediatric First Aid present during this inspection. During this inspection opening and closing teachers did not have pediatric first aid and cpr certificates on file. LPA also reviewed four staff records. The review of Staff records was documented on the LIC 859. All staff have been given on the-job training sanitation principles, housekeeping, including universal health precautions. Staff#2 did not have Health screening LIC 503 and proof of immunization against measles and pertussis on file. Staff#1 and staff#2 did not have required mandated reporter training certificate on file.

Children's roster was reviewed and is current. Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. LPA observed sign in/out sheet was placed outside by the entrance door. During this inspection 7 children were present, and 5 children were signed in. Disaster drill log was available, last drill was conducted on 07/25/25.

Menus are posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. Snacks were reviewed for availability, quantity and appropriateness to children in care. Preschoolers bring their own lunch and snacks from home. Facility provides optional AM and PM snacks.

First Aid supplies were observed in each classroom. According to the director, the facility does not administer any medication to children at this time. The facility was observed to be equipped with an isolation area for any child who becomes ill and it is located in the staff office. The ill child will use the outside restroom during isolation which is disinfected immediately after use.

Medication: Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (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


REPORT CONTINUES ON NEXT PAGE 3 OF 4
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486
VISIT DATE: 09/11/2025
NARRATIVE
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Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCsthat are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing. Per director, Water Lead Testing was completed on 02/07/24.

LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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.

Exit interview conducted and report was reviewed with the director, Niranjala Bibile.


END OF REPORT PAGE 4 OF 4
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/11/2025 03:19 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/11/2025 at 12:30 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. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.2(d)(1)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (1) In a safe condition for the activities planned.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation on this date the licensee did not comply with the section cited above and LPA observed outdoor play structure area was full of dust, leaves, and spider webs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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2
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Per director, she did not take children to the play structure area during summer due to the head. Per director, she will clean the outdoor play structure area by 09/30/25.
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 staff files review, the licensee did not comply with the section cited above and staff#1 and staff#2 did not have required mandated reporter training certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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2
3
4
Per director, staff#1 and staff#2 will complete required mandated reporter training by 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2025 03:19 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/11/2025 at 12:30 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. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025

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 staff files review, the licensee did not comply with the section cited above and staff#2 did not have proof of immunization on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Per director, staff#2 will have proof of immunization against measles and pertussis by 09/30/25.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff files review, the licensee did not comply with the section cited above and staff#1, opening teacher and staff#3, closing teacher did not have current pediatric first aid and cpr certificates on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Per director, staff#1 and staff#3 will have current pediatric first aid and cpr certificates by 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2025 03:19 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/11/2025 at 12:30 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. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025

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 staff files review, the licensee did not comply with the section cited above in 1 out of 3 staff, staff#2 did not have health screening form LIC 503 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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2
3
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Per director, staff#2 will have health screening form LIC 503 by 09/30/25.
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 8 children files review, the licensee did not comply with the section cited above and 1 out of 8 children, child#2 did not have physician report LIC 701 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Per director, she will have child#2 physician report form, LIC 701 on file by 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 09/11/2025 03:19 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/11/2025 at 12:30 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. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MONTESSORI ACADEMY
FACILITY NUMBER: 198004486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation and review of sign in/out sheet, the licensee did not comply with the section cited above in 2 out of 7 present children did not sign in on sign in sheet today which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per director, she will remind the parents to sign in/out daily.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


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