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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009556
Report Date: 10/10/2025
Date Signed: 10/10/2025 02:02:05 PM

Document Has Been Signed on 10/10/2025 02:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GARCIA FAMILY CHILD CAREFACILITY NUMBER:
198009556
ADMINISTRATOR/
DIRECTOR:		GARCIA, ROSA MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 768-7549
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
10/10/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Rosa Maria Garcia, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On Friday, October 10, 2025 Licensing Program Analyst (LPA) Evelyn Garcia conducted an unannounced annual inspection and met with Rosa Maria and guided LPA Garcia on a tour of the facility. There were 2 children in care participating in playtime, both children are under 24 months. Operating hours are Monday- Friday, 6:00am- 6:00pm. Residing in the home are licensee and spouse, both who have been fingerprinted and cleared. This facility is a single-story home that consists of 3 bedrooms, 3 bathrooms, kitchen, living area, dining room, attached garage, and front yard and backyard fenced.

Areas off limits to children include- Bedrooms #2 and #3, Bathroom located inside a bedroom that is off limits, back yard, and detached garage.

Areas on limits for the children include living room, kitchen, bedroom #1 (daycare playroom), bathroom (hallway on the right).

LPA Garcia inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone & landline). For ventilation, LPA Garcia observed central AC and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. Per licensee there is a crib for nap time but LPA did not observe. Licensee stated that the children just started and had the crib outside. LPA instructed licensees to bring crib into an area that is on limits, due to infant falling asleep. LPA informed licensee that the infant could not sleep on the couch.

LPA Garcia observed cleaning compounds items stored under the kitchen sink, however the safety latch was not secured making the cleaning materials accessible to the children.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/10/2025 02:02 PM - It Cannot Be Edited


Created By: Evelyn Garcia On 10/10/2025 at 01:12 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: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed cleaning compounds, (ajax, cleaning powders, shampoos, window cleaner, steel cleaner) accessible to the children in care (bathroom and kitchen). LPA observed a mobile child, easily open shower door and have access to other hazardous products.
POC Due Date: 10/13/2025
Plan of Correction
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Licensee will place safety latch on shower door to prevent children from accessing hazardous items stored in the shower and will ensure all hazourdous items around the home are inaccessible to the children or secured in a cabinet with a child proof lock.
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.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Evelyn Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 02:02 PM - It Cannot Be Edited


Created By: Evelyn Garcia On 10/10/2025 at 01:12 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: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Per licensee, stated that the company that services them comes every year but doesnt know why they have not serviced them recently.
POC Due Date: 10/14/2025
Plan of Correction
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Licensee will call company to have them serviced as soon as they are available.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee stated that she thought documentation was only for children under 12 months, and has been doing documentation but lost the documentation.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee will immediatley begin documentation during the infant's nap time until their 2nd birthday, and show proof to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Evelyn Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556
VISIT DATE: 10/10/2025
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In addition, cleaning materials were observed on the kitchen cabinet and around the sink area, accessible to the children. Knives are stored in a kitchen cabinet that is inaccessible to the children. For water drinking, licensee stated filtered water is dispensed and bottled water. Licensee currently participates in a food program.

LPA Garcia entered bathroom #1 (hallway on the right) accessible to the children, and observed the toilet, hand washing sink, hand soap. Cleaning materials were observed to be stored in the bathroom. LPA observed Ajax, shampoos, conditioners in the shower that is easily accessible to the children. Items that are considered hazardous to the children were placed by the licensee into in a high cabinet above the toilet and secured with a safety latch. LPA observed the restroom to be in operable condition. LPA advised the licensee to purchase a safety latch for the shower as it was easily accessible to the mobile infant, which licensee observed her to easily roll the shower door open. Licensee was observed to have several shampoo bottles on the floor of the shower.

LPA Garcia asked the licensee if there were any pets, poisons, firearms, weapons. The licensee stated there are no pets, no poisons, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, or weapons. The license was informed that if any poisons (ex; Drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.



LPA Garcia inspected the front yard and observed play houses and other age appropriate materials for the children. The back yard is fenced by a iron gate and remains locked with a hinge lock when children are outside. Per licensee the children use the front yard when the sun goes down due to the heat. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA did not observe hazards, sharp or loose, pointed parts.
The surface of the outdoor activity space (concrete) is maintained in a safe condition and is free of hazards and consists of concrete and thick foam rubber matting.

For outdoor water drinking, licensees bring out individual water cups or disposable and refilled as needed.

LPA Garcia observed the required 2A10BC fire extinguisher located in the daycare living room with the valve on the green.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556
VISIT DATE: 10/10/2025
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However, it was last serviced on 11/1/23. LPA advised licensee that the fire extinguisher must be re-purchased or serviced on a yearly basis. LPA observed the dual smoke/carbon monoxide detector in the daycare playroom above the door. The licensee tested the carbon monoxide and smoke alarm. LPA Garcia heard the sounds and are operable. LPA observed the first aid complete. For ill isolation, licensee stated the Livingroom is used for ill isolation until parents pick up the child. Per licensee the last disaster was a couple months ago but lost the drill log. Per licensee the facility Roster is lost.

LPA Garcia observed licensee Pediatric First Aid/ CPR certification dated 12/8/25. Licensee stated she has already done the Health and Safety certification, but cannot find the certification. LPA instructed licensee to take course and show proof of completion. Child Abuse Mandated Reporter (AB 1207) 3/13/25. Licensee did not produce proof of immunization against Pertussis, Measles, and Influenza. Per licensee she does not know where she has the records. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA observed all of the required postings which include Facility Sketch, Notification of Parent’s Rights, Earthquake Preparedness, Disaster Plan, License.

The following was also discussed with the licensee:



1. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

2. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

4. 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.

5. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556
VISIT DATE: 10/10/2025
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6. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

7. 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 624B). Mandated reporter requirements were reviewed and explained.

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

9. Smoking is prohibited in the family childcare home.



10. Children and staff records must be maintained and updated as needed and be available for review by the Department.

11. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

12. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



13. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

14. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

15. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

16. Dog(s) and/or pets are recommended to be isolated from children in care.

17. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556
VISIT DATE: 10/10/2025
NARRATIVE
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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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

LPA discussed the safe sleep regulations with 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 licensee 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) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee 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: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 198009556
VISIT DATE: 10/10/2025
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Corrections: 1) Will make a facility roster and submit to LPA 2) Licensee will take health and safety course and submit to LPA 3) Licensee will get copies of her vaccines and submit to LPA for proof and file in facility licensing file. 4) Licensee will have fire extinguishers replaced or serviced and submit proof to LPA. 5) Licensee will document sleep log and show proof to LPA. 6) Licensee will ensure cleaning compounds are made inaccessible to children

During the exit interview, the Licensee, Rosa Maria confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There are 2 Type B violations, and 1 Type A violation being cited today. Please see 809-D for more information.

Upon receipt of a Type A deficiency, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

An exit interview was conducted, and a signed copy of this report was provided to the licensee, Rosa Maria Garcia.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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