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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021544
Report Date: 09/08/2026
Date Signed: 09/08/2026 04:18:13 PM

Document Has Been Signed on 09/08/2026 04:18 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:EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CAREFACILITY NUMBER:
198021544
ADMINISTRATOR/
DIRECTOR:		EDIRIMUNI,TENURIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 680-7604
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
09/08/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Tenuir Edirimuni, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 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 09/08/26 at 12:40PM, Licensing Program Analyst (LPA) Diana Ortiz conducted an unannounced annual random inspection to the above facility. LPA was greeted by Licensee Tenuri Edirimuni to whom the reason for the visit was explained. Licensee then guided LPA on a tour of the facility. Census was taken and LPA observed eight (8) children in care. Per Licensee, there are currently 12 children enrolled. The children's roster was reviewed and is current. Hours of operation are from Monday through Friday from 6am-6pm. The licensee was observed to be operating within the license capacity limitations at the time of inspection. LIC 126 Entrance Checklist was provided to Licensee.

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan.

This is a single-family home which consists of 3 bedrooms, 2.5 bathrooms, dining area (daycare room), living room (main daycare room), kitchen, front yard, back yard, enclosed side yard, and garage. Currently residing in the home are four (4) adults and zero (0) minors. There was a total of two (2) adults present during this inspection, Licensee and licensees assistant. All adults present at time of inspection are fingerprint cleared and associated to facility in Guardian.

Areas accessible to children include: the living room (main daycare room), dining area (daycare room) the ½ bathroom, and enclosed side yard.
Page 1 of 5
Brandi VanOosten
Diana Ortiz
DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2026
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 8
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 8
Document Has Been Signed on 09/08/2026 04:18 PM - It Cannot Be Edited


Created By: Diana Ortiz On 09/08/2026 at 01:36 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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, interview, and record review, the licensee did not comply with the section cited above in conducting fire/disaster drills at least once every six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
1
2
3
4
Per Licensee, they will conduct fire/disaster drill and provide proof to LPA by POC due date.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in physically checking on infants every 15 minutes while sleeping which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
1
2
3
4
Per Licensee, she will check infant every 15 minutes while they are sleeping and document and provide 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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Diana Ortiz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/08/2026 04:18 PM - It Cannot Be Edited


Created By: Diana Ortiz On 09/08/2026 at 01:36 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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in Staff #2 (S#2) did not conduct AB1207 training, last training expired on 03/2026 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
1
2
3
4
Per Licensee, S#2 will take AB1207 training and provide proof to LPA by POC due date.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in two (2) out of five (5) children files were missing proof of immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
1
2
3
4
Per Licensee, she will ask parents to provide proof of immunization records for children and provide 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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Diana Ortiz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544
VISIT DATE: 09/08/2026
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
 Per Licensee, areas off limits to children and parents are: front yard, back yard, 3 bedrooms, 2 bathrooms, kitchen and garage. LPA observed that doors are kept closed and locked. During this visit, all areas identified on the facility sketch that are accessible for children to use were toured and inspected.

Tour began in the dining room, which is also utilized as a daycare area. LPA observed age-appropriate toys, equipment, and materials available for the children in care. LPA observed two (2) play yards that appeared to meet Title 22 requirements. A changing table was also observed and was equipped with diapers and baby wipes. During the inspection, LPA observed stuffed animals and blankets inside the play yards while children were sleeping. During the inspection, Licensee removed the items from the play yards. A Technical Violation was provided regarding this observation. LPA observed individual cubbies labeled with each child’s name. The children’s diapers were stored in their respective labeled cubbies. LPA observed a fireplace located in the dining room area. The fireplace is constructed of brick and was covered with a wood panel, making the fireplace inaccessible to children in care. Pool noodles/cushioning were observed surrounding the brick portion of the fireplace. LPA also observed gates being used to restrict children’s access to areas of the home that are not accessible to children in care. Per Licensee, the children use the bathroom located in the hallway near the kitchen/laundry room. Licensee stated that children who use the restroom are accompanied and walked to the restroom at all times. LPA observed the children’s bathroom to be maintained in a safe and sanitary condition. LPA observed the living room, which is utilized as the primary daycare area for the children. LPA observed two (2) cribs and two (2) play yards that appeared to meet Title 22 requirements. LPA also observed age-appropriate toys, equipment, and reading materials available for the children in care.

Per licensee, the children will have access to the side yard area. LPA observed a small play structure in the enclosed side yard along with toys. The patio where children are playing is enclosed with a 6-foot gate and cement wall. The area has artificial grass to absorb falls. LPA advised Licensee that outdoor supervision is required at all times. LPA observed age-appropriate toys free of loose and sharp parts available for the children in the backyard and all trees, shrubs, and plants are maintained.

Licensee states that she is part of a food program called CDA, and provides the following meals: Breakfast, lunch, and afternoon snack for children in care. LPA advised that if parents do provide food, baby food, and formulas it must be labeled with child’s name and stored appropriately.

Page 2 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544
VISIT DATE: 09/08/2026
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
LPA advised that breast milk should have the date and child’s name written on the bottle. Per Licensee, there is central air and heating in the home.

Per Licensee, the ill/isolation area is in the living room/day care area in a separate section. The children will wait on a mat or chair for parents or authorized representatives to pick them up.

Detergents, cleaning compounds, and medications were observed to be inaccessible to children. LPA advised that any poison should be locked under key or combination lock. Per Licensee, there are no weapons, firearms in the home and there are no bodies of water around the premises. LPA did not observe any weapons/firearms, or bodies of water around the premises at time of inspection.

The valve on the required 2A 10BC fire extinguisher indicates fully charged. The fire extinguisher was purchased on 08/01/2026 and purchase receipt was attached. Smoke and carbon monoxide detectors were tested and were operable on this day. During the inspection, Licensee stated that she did not recall the date of the last fire and disaster drill and was unable to provide LPA with documentation indicating when the drills were last conducted. This poses a potential risk to the health and safety of children in care. Reminded Licensee all homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill.

The home is observed to be clean and orderly. There are first aid supplies available located in the daycare area. LPA observed that there are age-appropriate toys available for children. Appropriate sleeping arrangements in form play yards, and mats were observed.

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. However, during file reviews, LPA observed two (2) out of five (5) children were missing immunization records in their files. This poses a potential risk to the health and safety of the children in care.

Page 3 of 5

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544
VISIT DATE: 09/08/2026
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
Licensee file was reviewed for the following: LIC 508- Criminal Record Statement, 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. LPA reviewed the required Pediatric First Aid and CPR certification for Licensee. The certification was observed to be current and expires in 11/2027. LPA also reviewed Licensee’s Mandated Reporter Training, which was observed to be current and expires in 12/2027.

During the inspection, LPA reviewed Staff #2’s (S#2) Mandated Reporter Training and observed that the AB 1207 Mandated Child Abuse Reporting training expired in 03/2026. S#2’s mandated reporter training was not current at the time of inspection. This condition poses a potential risk to the health and safety of children in care. LPA reminded Licensee that, pursuant to AB 1207, individuals who work in a child care facility are required to complete mandated reporter training and renew the training every two (2) years. Licensee was advised to ensure that all staff maintain current mandated reporter training as required. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

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

LPA did not observe the following items during the inspection: Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family childcare facility.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee 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 licensee 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: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: EDIRIMUNIAND ABEYSEKARA FAMILY CHILD CARE
FACILITY NUMBER: 198021544
VISIT DATE: 09/08/2026
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/.

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

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 Licensing staff 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 Tenuri Edirimuni.

Page 5 of 5

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC809 (FAS) - (06/04)
Page: 8 of 8