198020571-5-21-2024-33-CC-VMGA-D5GTA3-20240521143253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020571
Report Date: 05/21/2024
Date Signed: 05/21/2024 02:33:12 PM

Document Has Been Signed on 05/21/2024 02:33 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:	ANGUIANO FAMILY CHILD CARE		FACILITY NUMBER:	198020571
ADMINISTRATOR/ DIRECTOR:	CLAUDIA LUIS ANGUIANO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 999-7014
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90042
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	05/21/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Claudia Anguiano		TIME VISIT/ INSPECTION COMPLETED:	02:50 PM

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This inspection was conducted in Spanish.

Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced Annual/Random inspection at the above facility on 05/21/24 at 09:05 a.m. LPA met with Claudia Anguiano, licensee who guided analyst on a tour of the facility. There were 06 children present during this inspection. Also present during this inspection was the licensee’s assistants Maria Mondragon and Raquel Quintero. Per licensee, 10 children are enrolled. Operation hours are Monday – Friday 06:00 a.m. to 05:00 p.m.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, living room, front and backyard (fenced). Areas accessible to children include: living room, 2 bedrooms (nap and activities), 1 bathroom (adjacent to the living room), front yard (fenced). Areas off-limits to children and parents include: 1 bedroom, 1 bathroom, kitchen, and backyard (fenced), Per licensee, there are no pets on the premises; however, licensee stated her daughter brings her dog and it’s kept in the backyard. According to the licensee, the dog is not around the day care children and is kept in the backyard. Per licensee, family members residing in the home are 2 adults and 0 minors. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing, or volunteering in a licensed home and are identified on the attached LIC811.

LPA toured all areas identified on the facility sketch used by children during this visit and were inspected for safety, comfort, and cleanliness. Tour began in the living room and LPA observed safe toys, play equipment, and materials for children. Adjacent to the living room is the front bedroom used by older children during nap time and activities. LPA also observed cots used as napping equipment used by older children. LPA toured the second bedroom (next to the children’s bathroom) and observed 4 play pens and a changing table. During inspection LPA observed Child 2 (C2) napping in a play pen covered with a blanket and the door closed. LPA advised licensee that the door must remain open while children are napping. Licensee immediately removed the blanket.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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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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: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
	VISIT DATE: 05/21/2024

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LPA observed that the play pens do not hinder the entrance or exit to and from the space they are sleeping in. LPA also observed licensee placed a well mounted gate between the living room and kitchen since the kitchen is off-limits. According to the licensee, infants eat in the kitchen only during lunch and snacks. The bathroom children use is adjacent to the living room. The bathroom children use was observed to be in safe and sanitary conditions. There’s also a first aid kit readily available.

LPA observed the following required posted documentation in the entrance/living room of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records LIC 610- Emergency Disaster Plan and Disaster drill log. 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 conducted was on 11/17/23. Children’s roster was available during this inspection and was observed to be current.

LPA did not observe any pools, spas, hot tubs, fishponds, or similar bodies of water during the inspection.

Licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary. **Rooms that are off-limits need to be made inaccessible during operating hours**

Per licensee, food is provided to children in care. Licensee was advised that if food is brought from the children’s homes, all containers must be labeled with the child’s name and properly stored or refrigerated. There is telephone service via landline and cellphone. There is ventilation and heating.

Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

At 09:50 a.m. smoke and carbon monoxide detectors were tested and are operable. The valve on the required 2: A 10 BC fire extinguisher indicates fully charged and was serviced on 09/14/22, per the attached service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually.

The isolation area for sick children waiting to be picked up is in the front bedroom with supervision.

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

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
	VISIT DATE: 05/21/2024

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Currently children use the front yard (fenced) for outdoor play with adequate shade and age-appropriate play equipment for children in care. LPA observed a small trampoline with some tears on the skirt and base. Per licensee, children use the trampoline one by one or in two’s and are supervised at all times. LPA advised the licensee to not allow the use of trampolines as recommended on our website under SHINE Element 6: Physical Activity. LPA provided a copy of the SHINE Element 6: Physical Activity. Trampoline should be replaced and follow manufactures guidelines. LPA also advised licensee to check with the American Standard Testing Materials for Playground Guidelines and/or to use the manufactures recommendations for the playground equipment in efforts to be more in line with safety guidelines. Licensee understands that children should be supervised at all times.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). LPA observed Child 1 (C1), C2, C4, and C6 are missing LIC 995A. LPA also observed licensee has been documenting infant safe sleep every 15-minutes; however, licensee is not consistent. Safe sleep log for the month of May for C2 documents only 05/06, 05/09, 05/13, 05/14, 05/17, 05/20 and for C6 05/06, 05/07, 05/13, 05/14, and 05/20. According to the licensee, C2 and C6 have been absent and therefore she did not document that on the safe sleep log.

Licensee and (2) assistant’s records were reviewed for approved Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Licensee’s Mandated Reporter Training expires on 08/10/24. Licensee’s Pediatric CPR/FA expires on 10/2025. LPA also observed assistant #1 Raquel Quintero took the Mandated Reporter General Training; however, she did not complete AB1207. LPA did not observe record of MMR, Tdap, and Flu record or declination letter for licensee and both assistants.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
	VISIT DATE: 05/21/2024

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Licensee is caring for infants. 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.

No infant walkers, No baby bouncers, No Johnny jumpers, No exersaucers and any other item that falls into that category.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. LPA observed licensee has an EPI Pen for C3; however, licensee did not have a prescription. 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 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.

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 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.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
	VISIT DATE: 05/21/2024

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Licensee Claudia Anguiano confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following deficiencies were cited in accordance with Title 22 of the California Code of Regulations and Health & Safety Codes. Please see 809D for documentation of deficiencies.

Exit interview conducted and report was reviewed with the licensee Claudia Anguiano.

Type A citation

LPA Veronica MartinezGarza informed licensee Claudia Anguiano that this report dated 05/21/24 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Veronica MartinezGarza informed the licensee Claudia Anguiano to provide a copy of this licensing report dated 05/21/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 05/21/2024 02:33 PM - It Cannot Be Edited

Created By: Veronica Martinez-Garza On 05/21/2024 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. 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 LPA observed child 2 was covered in a blanket which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	Licensee immediately removed the blanket. LPA advised licensee to review the regulations for Safe Sleep and to watch the video on the website ccld.ca.gov.

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.

SUPERVISOR'S NAME:

Ana Chico

LICENSING EVALUATOR NAME:

Veronica Martinez-Garza

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 6 of 9

Document Has Been Signed on 05/21/2024 02:33 PM - It Cannot Be Edited

Created By: Veronica Martinez-Garza On 05/21/2024 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA observed the fire extinguisher was last serviced on 09/14/22, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2024
	Plan of Correction
1 2 3 4	Per licensee, she will service the fire extinguisher and will submit proof to LPA by POC due date.

Type B

Section Cited

CCR

102417(g)(9)(A)

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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 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 LPA observed the last fire and disaster drill was conducted on 11/17/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2024
	Plan of Correction
1 2 3 4	Per licensee, a fire and disaster drill will be conducted and will submit proof to LPA 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.

SUPERVISOR'S NAME:

Ana Chico

LICENSING EVALUATOR NAME:

Veronica Martinez-Garza

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 05/21/2024 02:33 PM - It Cannot Be Edited

Created By: Veronica Martinez-Garza On 05/21/2024 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in Licensee and both assistants do not have proof of MMR, Tdap, and Influenza which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Per licensee, she will submit proof of immunizations to LPA by POC due date.

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.

SUPERVISOR'S NAME:

Ana Chico

LICENSING EVALUATOR NAME:

Veronica Martinez-Garza

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9

Document Has Been Signed on 05/21/2024 02:33 PM - It Cannot Be Edited

Created By: Veronica Martinez-Garza On 05/21/2024 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANGUIANO FAMILY CHILD CARE	FACILITY NUMBER: 198020571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). 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 LPA observed Child 1 (C1), C2, C4, and C6 are missing LIC 995A which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2024
	Plan of Correction
1 2 3 4	Per licensee, proof of complete LIC 995A will be submitted to LPA 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.

SUPERVISOR'S NAME:

Ana Chico

LICENSING EVALUATOR NAME:

Veronica Martinez-Garza

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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