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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020053
Report Date: 05/05/2025
Date Signed: 05/05/2025 02:05:13 PM

Document Has Been Signed on 05/05/2025 02:05 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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:LITTLE ANGELS PRESCHOOL & KINDERGARTENFACILITY NUMBER:
198020053
ADMINISTRATOR/
DIRECTOR:		SAVITRI YASODA ABEYAWARDENFACILITY TYPE:
850
ADDRESS:18419 S. AVALON BLVDTELEPHONE:
(310) 819-8629
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 51DATE:
05/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee / SAVITRI YASODA ABEYAWARDENTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 05/05/25 at 9:15pm, Licensing Program Analysts (LPAs) Ashley Calderon and Susann Sanchez conducted an unannounced random/annual inspection at the above facility. LPAs met with Teacher Anthonesha Recions who allowed LPA's entrance into the facility. LPA's disclosed the purpose of the visit wirh Licensee Savitri Abeyawardene .

Facility Hours of Operation are Monday to Friday 7am to 6pm. Facility License States: LICENSE TO CARE FOR PRESCHOOL FROM 2 - ENTRY INTO KINDERGARTEN. Children roster and staff personnel LIC500 was reviewed.

All areas identified on this report were inspected. Upon arrival, LPAs observed this facility is one big classroom but it is divided into 3 parts using cubbies (3 classrooms). Teacher-child ratios were observed to be in accordance with Title 22 Regulations. All children were observed to be under visual supervision of a teacher at all times. The facility has a capacity of 48 children, children census was 50 children upon arrival and day care at 11:25am an additional children arrived at the facility making census 51, Type A deficiency cited.

LPAs observed all preschool classroom to be clean and in good repair. The floors were clean and lighting was in operable condition. There were age appropriate toys and equipment. LPA observed water readily available via water fountain and water bottles. LPAs observed cubbies/storage area for children to store their personal belongings. Smoke detector and carbon monoxide was observed to be interconnected and were observed to be in operable condition. (Pg 1 / Cont...)
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Susann Sanchez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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 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)
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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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053
VISIT DATE: 05/05/2025
NARRATIVE
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 LPA observed Fire extinguisher located near the kitchen and was serviced within 1 year. First Aid kit was observed and inventoried, all items were present. Appropriate sinks and toilets were inspected for availability, good repair and general sanitation. Disinfectants and cleaning solutions are inaccessible to children in care, locked in Shed in the outdoor play yard.

Napping equipment cots are used and bedding were inspected and found to be clean placed in children backpack/cubbies. Per S. Abeyawardene, bedding sheets are sent home on Fridays to be washed and brought back upon children's return.

Per S. Abeyawardene currently there (5) children on medication. Medication is administered on a as needed basis. Medications are stored in medication box inaccessible to children in care. 2 out of 5 children medications were expired, pictures taken, deficiency cited, Type A.

LPA stoured the outdoor play area. LPA observed age-appropriate toys and material for children. LPAs observed required cushioning under climbing structure to absorb a fall. LPAs observed a wooden walking bean in the play yard. Wooden bean had fabric material torn apart, hanging from bean which can cause children to fall. Per S. Abeyawardene when LPA Calderon asked if children use the wooden bean, Abeyawardene stated children use it sometimes, Type B was cited. Shade was observed in the outdoor area. Children use the water fountain during outdoor play. LPA did not observed bodies of water on the premises.

LPA observed the kitchen area, food preparation area, and food storage area to be clean and free of litter, rubbish, rodents, and/or any other vermin. LPA observed refrigerator to be clean and in operable condition. Food is prepared at the facility.

LPA observed a current Children's roster. LPAs observed required posted documentation which included, Facility License, LIC610- Emergency Disaster Plan, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, and Lunch/Snack Menus. All documents were observed to be posted in the main lobby area. LPAs observed Sign in/out sheets using Online System, LIC 9148 Earthquake Preparedness form, Daily Activity Schedule posted in each classroom, and Verification of Disaster and Fire Drill documentation was observed: last conducted on April 2025. (Pg2 / Cont...)
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Susann Sanchez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053
VISIT DATE: 05/05/2025
NARRATIVE
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Children’s records were reviewed for LIC 613A- Personal Rights, Admission Agreement, Immunization Records, LIC 700- Identification and Emergency Information, LIC 701- Physician’s Report, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights. All children had proper documentation's.

(8) Staff records were reviewed. Staff 8 - missing LIC 503- Health Screening Report and immunization's not in file, Staff #7 missing MMR and Immunization records for Staff #2 not in file, Personnel Records for staff were incomplete , deficiency cited. Licensee Mandated Reporter Training Certificate expired, Licensee stated has to renew training, deficiency cited.

All staff present at the facility are fingerprinted cleared. Facility has 3rd parties come to the facility example: Behavioral Therapist and Webby Dance Company whom are listed on the LIC500 Personnel Staff Roster.

LPA's gave consultation on Technical Support Program (TSP) information was provided, Per S. Abeyawardene would like to participate in TSP and LPA Calderon will enroll facility.

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, 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.

(Pg 3./ cont...)

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Susann Sanchez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 02:05 PM - It Cannot Be Edited


Created By: Susann Sanchez On 05/05/2025 at 11:46 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
101226(e)(6)
101226(e)(6) Health-Related Services. When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of medication for Child #1 & #2, the licensee did not comply with the section cited above in [2] out of [5] children on medication prescription which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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By poc due date Staff will contact children's parents to see if the children need a new medications or is withdrawing from medication stored at the facility. Licensee stated will create a log with medication list and expiration dates for each child, Licensee will send a log and provide log to LPA Calderon by 5/26/25.
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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Susann Sanchez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 02:05 PM - It Cannot Be Edited


Created By: Susann Sanchez On 05/05/2025 at 12:35 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

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
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Based on observation LPA's observed outdoor wooden bean having fabric material ripped apart, hanging off bean, per SAVITRI YASODA ABEYAWARDEN stated soemtimes children use it, the licensee did not comply with the section cited above in [1] out of [1] outdoor wooden bean object that can cause a fall, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Send picture of fixed wooden bean to LPA Calderon via email by poc due date.
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 record review Licensee Mandated Repoter expired SAVITRI YASODA ABEYAWARDEN stated needs to re new training, the licensee did not comply with the section cited above in [1] out of [1] mandated reporter training expired, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee will conduct Child Care Provider Mandated Reporter Training certfication and send to LPA Calderon via email by poc due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Susann Sanchez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 02:05 PM - It Cannot Be Edited


Created By: Susann Sanchez On 05/05/2025 at 01:10 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101179(a)
(a) A license shall be issued for a specific capacity, which shall be the maximum number of children that can be cared for at any given time. The Department may issue a license for fewer children than requested.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation there was a census LPA Calderon and Sanchez observed 51 child by 11:25am and by record review of the sign in, on Brightwheel App, and License if for a capacity of 48 children , the licensee did not comply with the section cited above in [3] out of [51] children over capcity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Facility Licensee stated 'will have children be on a waitlist, become half time, or disenroll children.' During visit Licensee talked to families of some children to create a plan. Facility will create a list of children that have a new plan implemented and send document to LPA via email by 5/12/25.
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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Susann Sanchez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053
VISIT DATE: 05/05/2025
NARRATIVE
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LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and


administrative records.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are 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.

Based on all information obtained on this date 5/5/25, based observation, interviews and record review deficiency listed on the following page LIC809-D is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 1 and Section CCR & H&S.



A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.

Exit interview was conducted with Licensee SAVITRI ABEYAWARDEN. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview conducted and report was reviewed with the licensee SAVITRI YASODA ABEYAWARDEN

(Pg 4/ End)

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Susann Sanchez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 02:05 PM - It Cannot Be Edited


Created By: Susann Sanchez On 05/05/2025 at 01:32 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE ANGELS PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 198020053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review Staff 2 missing immunization records , Staff 7 missing Tdap and Staff #8 missing Health Screening and Immunization records, the licensee did not comply with the section cited above in [3] out of [3] staff personnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
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Staff will get vaccinated or obtain immunization and/or health screening records and provide copy to LPA Calderon by poc due date.
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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Susann Sanchez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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