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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020316
Report Date: 06/04/2025
Date Signed: 06/04/2025 12:51:46 PM

Document Has Been Signed on 06/04/2025 12:51 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:FLORES FAMILY CHILD CAREFACILITY NUMBER:
198020316
ADMINISTRATOR/
DIRECTOR:		CYNTHIA FLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 347-0133
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 3DATE:
06/04/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Cynthia Flores, Licensee TIME VISIT/
INSPECTION COMPLETED:
01:15 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
At 9:15 am Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced annual random inspection to the above facility. LPA met with Licensee, Cynthia Flores, to whom the reason for the visit was explained. Per Licensee, there are 15 children currently enrolled. There were 3 children present- all infants. Also present was 1 assistant/ licensee’s daughter.

At 9:41 am LPA and Licensee walked into the den/ dining room area and observed Child #1 sleeping in a car seat on top of the dining table. Picture was taken- Assistant was observed coming in from the back yard and standing closer to the other 2 infants. LPA advised that child could not be in car seat and asked for child to be removed from car seat. Per Licensee, child was placed in car seat by Assistant when LPA arrived so they could open door as Licensee was changing a diaper. LPA advised that all car seats should be left outside and only used for transportation.

The licensee states that 5 adults and 1 child currently live in the home. Per Licensee, there are two assistants working at the facility. All adults living in the home have obtained a criminal record clearance.

This is a two-story home which consists of the following rooms: Downstairs contains a kitchen, dining room, living room, den, 2 bedrooms, and 2 bathrooms. Upstairs contains 2 bedrooms and 1 bathroom. The home also contains a detached garage, front yard which is not fenced, and backyard which is fenced and contains a built-in swimming pool. -------------------- pg. 1 of 5-------------------------
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316
VISIT DATE: 06/04/2025
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
Per licensee, areas off-limits to children and parents include the entire upstairs (2 bedrooms, 1 bathroom), and downstairs areas including 2 bedrooms, 1 bathroom, living room detached garage. The children have access to kitchen, dining room, one bathroom, living room, den area, swimming pool during the summer and front yard which is not fenced.

Licensee guided analyst on a tour of the facility. During this visit, all areas identified on the facility sketch that are accessible for children to use were toured and inspected and the following was observed.

Facility License, Emergency Disaster Plan, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the entry way of the home. A current children’s roster was available for review.

There is telephone service via a cellphone that stays at the facility during operation hours. Hours of operation are Monday – Friday, 6:30 am – 9:00 pm. LPA observed a fireplace in the den that has a screen bolted to the brick making it inaccessible to children. LPA also observed the stairs to the second floor of the home are made inaccessible to children by a metal safety gate at the bottom of the stairs. LPA observed 3 wall unit heaters to which the gas has been shut off per a proof of service order from the gas company and a declaration by the licensee.

Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee there are no poisons in the home. LPA advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms or weapons stored in the home.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 6/2/2025 as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable on this day. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 5/22/2025.

-------------------------------------------------- Pg. 2 of 5----------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316
VISIT DATE: 06/04/2025
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
There are first aid supplies available. There are age-appropriate toys available for children. Appropriate sleeping arrangements in form of cots and 2 cribs were observed.

LPA discussed the safe sleep regulations with licensee 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.



Sleep log and LIC 9227 individual plan was on file for all infants enrolled. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family child care facility.

Currently, children are using the front yard for outdoor play time. The outdoor play area is not fenced. Licensee stated she will provide 100% visual supervision of all children at all times while in the front yard. LPA observed that the outdoor yard has toys and other materials for children to play with.

LPA observed a pool in the back yard of the home- per Licensee the pool is used by children during the summer and 100 % supervision is provided. LPA observed the pool is fully fenced with a self latching gate. The metal gate to access the pool is at least 5 feet high and does not obscure the pool from view. There are 2 windows that lead directly to the pool from the den. The 2 windows are screened with a metal screen that is screwed into place.

At 9.48 am LPA observed that licensee does not have the required pool alarm detecting an entrance to the pool, life ring, rescue pole with body hook and daily inspection log. Per Licensee they have the alarm but have not installed it- LPA did observed the alarm in the box.

----------------------------------------------------- pg. 3 of 5-------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316
VISIT DATE: 06/04/2025
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
Children’s records were reviewed, including emergency information and were observed to be complete. Licensee and staff records were reviewed, and LPA advised that Staff #2 is missing Tdap and MMR immunizations. The licensee's Pediatric First Aid and CPR form the American Red Cross expires on 2/22/2027. Licensee’s Mandated Reporter Training expires on 6/3/2027.

There are 2 dogs and 2 cats on the premises. Per licensee, the dogs are kept outside in off limits areas during daycare hours.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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/.

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.

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

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

------------------------------------------------ og. 4 of 5 --------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316
VISIT DATE: 06/04/2025
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
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.

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 the LPAs observations and records 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.

Exit interview conducted and report was reviewed with the licensee, Cynthia Flores.

------------------------------------------------------- Pg. 5 of 5-------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/04/2025 12:51 PM - It Cannot Be Edited


Created By: Roxana Lopez On 06/04/2025 at 12:17 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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

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 that LPA observed alarm still in box and not set up in the pool which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
1
2
3
4
Per Licensee, they will set up the alarm and have it available for department review by POC due date of 7/4/2025
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

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 that Licensee has not purchased a life ring available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
1
2
3
4
Per Licensee, they will buy life ring and have it available for department review by POC due date of 7/4/2025
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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 06/04/2025 12:51 PM - It Cannot Be Edited


Created By: Roxana Lopez On 06/04/2025 at 12:17 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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

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 that Licensee did not purchase rescue pole which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
1
2
3
4
Per Licensee, they will buy rescue pole and have it available for department review by POC due date of 7/4/2025
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

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 that there was no daily log available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
1
2
3
4
Per Licensee, they will begin daily log and have it available for review by poc due date of 6/4/2025
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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 06/04/2025 12:51 PM - It Cannot Be Edited


Created By: Roxana Lopez On 06/04/2025 at 12:17 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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 198020316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

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 that child # 1 was sleeping in car seat on top of a table which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
1
2
3
4
Child was placed in crib during inspection- Per Licensee they will submit a written plan to remian in compliance by POC due date of 6/18/2025
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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10