<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018405
Report Date: 07/07/2026
Date Signed: 07/07/2026 03:49:54 PM

Document Has Been Signed on 07/07/2026 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KEYSTONE MONTESSORI PRESCHOOLFACILITY NUMBER:
198018405
ADMINISTRATOR/
DIRECTOR:		NOHELLY RIOSFACILITY TYPE:
850
ADDRESS:7056 WASHINGTON AVE.TELEPHONE:
(562) 303-7273
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 53TOTAL ENROLLED CHILDREN: 26CENSUS: 18DATE:
07/07/2026
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Director, Laura Perez TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/7/26, Licensing Program Analyst (LPA) Lilli Babcock conducted an unannounced annual inspection. LPA met with Director, Laura Perez, to whom the reason for the visit was explained. This is a preschool program which is currently licensed for a capacity of 53 children and operates Monday – Friday from 7:00 AM – 6:00 PM. Per Director there are 26 children enrolled.

Census was taken upon arrival and the following staff and children were observed by LPA to be present: Room 117: No children or staff present as Director states the room is usually only used as a playroom in the morning or afternoon to combine the preschool classrooms. Per Director the toddler children are not combined with the preschool children. Room 112: One staff with eight children observed in the classroom. Room 115: One staff with five children observed in classroom. The facility has a toddler option with a capacity of 8 children. LPA observed one staff with five children in the toddler classroom, Room 110. Staff names were recorded. Staff were observed to have fingerprint clearance. All children were observed by LPA to be under supervision, including visual supervision, of a teacher at all times.

All areas identified on the Facility Sketch were inspected and the following was observed: All indoor classrooms were inspected to ensure that furniture and equipment are age-appropriate and in good repair, and the floors have a surface that are safe and clean.
Page 1 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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 9
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)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 07/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the tour, LPA observed the carpet in the toddler classroom to have dark areas which appeared to be dirty or stained. A picture was taken. Director stated the carpet has not been cleaned in at least the last year or so. LPA advised Director to ensure carpets are cleaned regularly in all the classrooms.

Napping equipment including cots and bedding were inspected. Per Director, parents take their children's bedding home to wash every Friday. Storage for children's belongings were inspected and LPA observed children have their own labeled cubbies to store their belongings. Per Director, children bring water bottles from home, labeled with children's names, and are allowed to drink freely at any time. Water bottles are refilled on demand from a water filtration spout on the sink or water bottles purchased from a store.

LPA observed toys and materials for children in the classrooms. Age-appropriate toilets were inspected for availability and good repair in restrooms used by children.

Food menus were reviewed. The facility provides breakfast, lunch, and PM snack. LPA inspected the kitchen, food preparation, and food storage areas. LPA observed the food storage area (closet) in Room 117 to have 2 cans of paint and 1 can of bonding primer on the shelf and the door to the food storage closet to be unlocked. LPA also observed a cart in the food storage closet with chicken bouillon which expired on 3/5/26, pepper which expired on 6/25/25, vanilla extract which expired on 8/19/25, and an open packet of Homestyle Mashed Potatoes. In the refrigerator located in the food storage closet in Room 117, LPA observed apple. orange. pineapple juice blend with an expiration of 4/22/26 and a loaf of white bread which expired on 6/11/26. On the shelf in the food storage closet in Room 117, LPA observed an open plastic package of buttermilk pancake and waffle mix which was not secured with a clip or bag and observed the interior of the mix to be exposed to the elements. LPA also observed a jar of peanut butter which expired 3/20/26 on the shelf. Pictures were taken of the paint and expired food.
Page 2 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 07/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Director states that there are no firearms on the premises. Per Director there are no children at the facility that currently use medications. Telephone service, heating, lighting, and ventilation were evaluated. Per Director, preschool has a cell phone that is kept at the facility during operation hours. LPA observed the facility to have operable carbon monoxide and smoke detectors on this day. LPA reviewed Disaster Drill log. Last drill was conducted on 3/11/26.

The facility has an outdoor play area that is fully fenced. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. Per Director, children bring their water bottles with them each time the classroom goes outdoors.

On the outdoor play yard, LPA observed a blue, hard plastic whale on a spring for children to ride on. LPA observed a hole in the plastic on the top of the whale and the whale to be missing a handle for children to hold onto. LPA did not observe any way for children to hold on while riding on the whale. LPA also observed a metal slide on the play yard. LPA observed the slide to not be hot to the touch during the tour of the facility and LPA observed the slide to be under a shade canopy. LPA advised Director to monitor the slide in case it gets hot in the heat and not let children on the slide if the slide gets hot. LPA also observed the outdoor padding on the play yard to be cracking and coming apart in places. LPA advised Director to maintain the padding in a safe manor and repair as needed if there is a tripping hazard.

Staff Records and Children’s Records were reviewed. Children’s files reviewed contain information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary. LPA observed 4 of 6 children’s files reviewed to be missing a signed admission agreement. Staff files were reviewed. LPA observed staff files reviewed contained current mandated reporter training and at least one person present has current Pediatric First Aid and CPR.
Page 3 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 07/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

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 as specified in Health and Safety Code section 1597.16.

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 (Interim Licensing Standards) outlined in PIN 21-21.1-CCP.

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-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for and removing any 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.

Page 4 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 07/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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/.

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.

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.

Based on LPA’s observations and record review, the following deficiencies listed on the attached LIC 809D (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 and safety.

A notice of site visit was given and must remain posted for 30 days.


An exit interview was conducted, and the report was reviewed with the facility representative, Laura Perez.

Page 5 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Lilli Babcock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/07/2026 03:49 PM - It Cannot Be Edited


Created By: Lilli Babcock On 07/07/2026 at 02:49 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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.3(b)
Indoor Activity Space
(b) The floors of all rooms shall have a surface that is safe and clean.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 toddler classrooms with dirty or stained carpet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
1
2
3
4
Director states facility will have the carpet in the toddler room cleaned.
Type B
Section Cited
CCR
101238.4(d)
Storage Space
(d) Combustibles, cleaning equipment and cleaning agents shall be stored in an area separate from food supplies in a locked cabinet or in a location inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 cans of paint and 1 can of bonding primer observed on the shelf in the accessible food storage closet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
1
2
3
4
Director states the facility will remove the paint from the food storage closet on 7/7/26, and make the food storage closet inaccessible to children in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/07/2026 03:49 PM - It Cannot Be Edited


Created By: Lilli Babcock On 07/07/2026 at 02:49 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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(o)(1)
Fixtures, Furniture, Equipment and Supplies
(o) Playground equipment shall be securely anchored to the ground unless it is portable by design. (1) Equipment shall be maintained in a safe condition, free of sharp, loose or pointed parts.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 blue, hard plastic whale on a spring for children to ride on. LPA observed a hole in the plastic on the top of the whale and the whale to be missing a handle for children to hold onto, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
1
2
3
4
Director states they will remove the ride-on toy whale.
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [count] out of 6 children's files reviewed which was missing a signed admission agreement, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
1
2
3
4
Director will obtain a signed admission agreement for all children's files.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/07/2026 03:49 PM - It Cannot Be Edited


Created By: Lilli Babcock On 07/07/2026 at 02:49 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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(19)
Food Service
(19) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 5 items of expired food in the food storage closet and refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
1
2
3
4
Director removed and threw away all expired food during the visit.
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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Lilli Babcock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
Page: 9 of 9