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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611715
Report Date: 03/20/2023
Date Signed: 03/20/2023 06:48:59 PM

Document Has Been Signed on 03/20/2023 06:48 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CHILDTIME CHILDREN'S CENTER INC.FACILITY NUMBER:
300611715
ADMINISTRATOR:RFACILITY TYPE:
830
ADDRESS:1000 S. STATE COLLEGETELEPHONE:
(714) 772-7225
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Director Ann SosaTIME COMPLETED:
07:00 PM
NARRATIVE
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(Page 1)
On 03/20/2023 Licensing Program Analysts (LPA) Giselle Lucero and Patricia Rivas conducted an on site visit for the purpose of a 1 year required inspection. LPAs and Director, Ann Sosa toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 5 infant staff and 16 infant children. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 6:30 AM - 9:00 PM., Monday through Sunday.

A review of the Facility Personnel Report Summary conducted on 03/20/2023 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During the inspection of the indoor activity space, the following was divulged, 4 out of 4 staff interviewed advised LPAs that today at approximately 11 a.m. there were 2 staff present with 8 infants and 1 of the infants was asleep, staff reported that they were advised from management to pull crib out in between the nap area and activity area, blocking the nap area doorway to maintain ratio. The following citation will be issued 101438.3 (c)(1) Indoor activity space for infants on the 809D form.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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
Document Has Been Signed on 03/20/2023 06:48 PM - It Cannot Be Edited


Created By: Giselle Lucero On 03/20/2023 at 05:39 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.

FACILITY NUMBER: 300611715

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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
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Based on record review, the director did not comply with the section cited above. Staff 1 (S1) was missing immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Director stated she will have S1 complete the mandated reporter training and submit a copy to LPA 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, the director did not comply with the section cited above. Staff 2 (S2) did not have a current mandated reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Director stated she will have S2 turn in her immunization records and provide copy 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:Judy Hanson
LICENSING EVALUATOR NAME:Giselle Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


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Page: 2 of 10
Document Has Been Signed on 03/20/2023 06:48 PM - It Cannot Be Edited


Created By: Giselle Lucero On 03/20/2023 at 05:39 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.

FACILITY NUMBER: 300611715

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review, the director did not comply with the section cited above. 4 out of 5 children's file reviewed did not have a needs and services plan in their file. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Director stated she will provide a copy of missing forms to LPA Lucero by POC due date.
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the director did not comply with the section cited above. 5 out of 5 children's files were missing a individual infant sleeping plan. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Director stated she will provide a copy of missing forms to LPA Lucero 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:Judy Hanson
LICENSING EVALUATOR NAME:Giselle Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/20/2023 06:48 PM - It Cannot Be Edited


Created By: Giselle Lucero On 03/20/2023 at 05:39 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.

FACILITY NUMBER: 300611715

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review, the director did not comply with the section cited above. 5 out of 5 children's files that were reviewed did not have a date. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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2
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Director stated she will provide a copy of missing forms to LPA Lucero by POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Judy Hanson
LICENSING EVALUATOR NAME:Giselle Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.
FACILITY NUMBER: 300611715
VISIT DATE: 03/20/2023
NARRATIVE
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Items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Food is prepared on site; breakfast, lunch and snacks are provided. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges.

There is drinking water available to children indoors by infant’s personal bottles and get refilled by the facility. Children nap in cribs and matts, and bedding is stored individually and is taken home at the end of the week to be washed and sheets that are used in the crib are washed weekly at the facility. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning turf material around the climbing equipment, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by infant’s water bottles and get refilled by facility. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Staff files were reviewed for staff present during the facility inspection on this date, 03 out of 03 staff files were reviewed. Health screening and immunization's as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. 1 out of 3 staff files reviewed was missing immunization records.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed child care providers, administrators, or employees of a licensed child day care facility to complete the mandated reporter training, and to renew the training every two years. 1 out of 3 staff files reviewed was missing a current mandated reporter training certificate in staff file. At least one staff member present possesses a current EMSA approved Pediatric CPR/First Aid certifications, which expires 11/2023.
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.
FACILITY NUMBER: 300611715
VISIT DATE: 03/20/2023
NARRATIVE
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(page 3)
Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 children's files were reviewed for LIC 613A Personal Rights, Admission agreement, LIC 700 Identification and Emergency Information, LIC 701 Physician’s Report, LIC 995 Notification of Parents’ Rights, LIC 627 Consent for Emergency Medical Treatment and Immunization Record. LPAs observed 11 infants from 0-12 months. At 3:20pm during children’s files reviews, 5 out of 5 files reviewed did not have LIC9227 Individual Infant Sleeping Plan in their files. At 3:25PM LPAs observed 4 out of 5 children’s file did not have a needs and services plan 101419.2 (a) infant needs and services plan.

Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm

The director was informed that Licensing Quarterly Updates are available at https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care The director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.
FACILITY NUMBER: 300611715
VISIT DATE: 03/20/2023
NARRATIVE
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(page 4)

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2022/CCP/PIN-22-06-CCP.pdf. Facility Director does not have lead training Certificate in file.

Safe Sleep Consultation provided with the Director.
LPA discussed the safe sleep regulations and 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 the directors 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.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative




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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.
FACILITY NUMBER: 300611715
VISIT DATE: 03/20/2023
NARRATIVE
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(Page 5)
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
Director was informed of the Child Care licensing webinars and to review
PIN 22-30-CCP for more information on how to access the Webinars on
On March 28. 2023 at 6:00 PM
Resources: https://ccld.childcarevideos.org/family-child-care-providers/

Staff interview was conducted with the Director during today’s inspection.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Type B: 1596.7995(a)(1) General Provisions and Definitions, 1596.8662(b)(1) Administration of Child Day Care Licensing, 101419.2(a) Infant Needs and Services Plan, 101419.2(b)(2) Infant Needs and Services Plan, 101419.3(a) Modifications to Infant Needs and Services Plan, 101438.3 (c)(1) Indoor Activity Space for Infants.

Exit interview conducted and report was reviewed with the Director, Ann Sosa. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 6 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.
FACILITY NUMBER: 300611715
VISIT DATE: 03/20/2023
NARRATIVE
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(Page 6)
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

End of Report.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/20/2023 06:48 PM - It Cannot Be Edited


Created By: Giselle Lucero On 03/20/2023 at 06:23 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHILDTIME CHILDREN'S CENTER INC.

FACILITY NUMBER: 300611715

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101438.3(c)(1)
The sleeping area for infants shall be physically separate from the indoor activity space.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview the director did not comply with the section cited above. 4 out of 4 staff interviewed advised LPAs on 3/20/2023 at approximately 11 a.m. there were 2 staff present with 8 infants and 1 of the infants was asleep, staff reported that they were advised from management to pull crib out in between the nap area and activity area, blocking the nap area doorway to maintain ratio. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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2
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Director stated she will abide regulation, retrain staff, obtain walkie talkies for infant rooms and submit copy of training and sign in sheet to LPA Lucero by POC 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:Judy Hanson
LICENSING EVALUATOR NAME:Giselle Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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