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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314181
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:38:24 PM

Document Has Been Signed on 12/13/2023 03:38 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:ZHANG, MINGQIONG & ZHANG, HANJIEFACILITY NUMBER:
304314181
ADMINISTRATOR:Z, MINGQIONG & Z, HANJIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 887-3581
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Zhang, Mingqiong & Zhang, Hanjie TIME COMPLETED:
04:00 PM
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On 12/13/2023, Licensing Program Analyst (LPA) Karen Navar and Vivian Trinh conducted an announced, in-person Pre-Licensing inspection for a change of location for a Large Family Child Care Home license. The LPA met with applicants Mingqiong Zhang and Hanjie Zhang who provided a tour of the home. A review of the Facility Personnel Report Summary indicates 5 adults live in the home. The adult residents received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are 0 minors living in the home.

The applicants stated that they are not registered with any Resource Foster Care agency and that she does not hold a Resource foster parent license. The applicants were reminded to notify the licensing office of any changes.

The applicant has completed an application for a change of location and is requesting a Large Family Childcare Home license. The applicant stated they will cease operation at 87 Rembrandt, Irvine CA 92629 once they get licensed at new location 111 White Jasmine, Irvine CA 92618. Applicants stated they are relocating due to needing more space. LPA reminded applicants that they may only operate one family childcare, and they must reside in the licensed location. Applicants stated that they both live at the facility and do not plan to operate a childcare at their other location, and they plan to rent the house out. Per the applicant, operation hours will be Monday – Friday 8AM-5:00PM. Care and supervision will be provided to children ages newborn to 2 years old (infants) up to school age. For the purposes of licensing, an infant is defined as any child 0 to 24 months of age.
All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a 2-story home or single-story home with 3 bedrooms, 3 bathrooms, and a loft upstairs, and 1 bedroom, 1 bathroom downstairs, a living room, a kitchen, a laundry room, a front yard (not fenced), a backyard (fenced), and a garage. There is no fireplace.
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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
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: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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Applicant has designated the entire upstairs, downstairs bedroom, large walk-in closet that is located between living room and front door entrance, and garage as off-limits areas. The applicant has a child proof safety gate at the bottom of the stairs to the 2nd floor, ensuring the 2nd floor is inaccessible to children in care. The applicant has made the downstairs bedroom in accessible to children by the means of a number keypad and lock. Large walk-in closet is inaccessible to children by the means of a child safety door latch. The garage is made in accessible to children by the means of a child safety latch on the doorknob.

The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

The applicant has designated the living room, bathroom located next to downstairs bedroom, entry way, porch, and back yard as the day care areas for children. LPAs reminded applicants with children having access to the entry way next to the front door that they must have supervision of children at all times. Applicants stated they will be using this area for art. Applicants have designated the porch as drop off area for childcare. Applicants have placed a child safety gate outside on porch to ensure inaccessibility to driveway and street.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. The applicant has 2 small step stools in the children’s bathroom. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPAs did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicants stated that there are no weapons or firearms on the premises. The LPAs informed the applicants that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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Smoke and carbon monoxide detectors were tested and are operable. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 3A-10BC fire extinguisher indicates fully charged and is located in front entry way. The fire extinguisher type 3A-10BC must be serviced annually or as often as necessary.

There are no animals.

Outdoor play activities will be conducted in the backyard. The backyard is appropriately fenced. LPA’s observed age-appropriate play equipment to be free from hazards. Applicants have two child safety gates on the sides of the house one gate is ensuring children inaccessibility to the air conditioner and garden. The second child safety gate is ensuring inaccessibility to the side gate that leads to the driveway There are no bodies of water on the premises. The applicant stated there is a community pool that is 15 minutes away and a community playground. Applicants stated that they will use the community playground but not the community pool. They will walk children over using a six seater stroller and a 4 seater stroller. LPA’s reminded them that if they use the playground to have complete supervision.

The applicants stated they will provide morning snack, lunch, and afternoon snack. If child has allergies applicants stated, they will talk with parents and that child will bring their own food from home. The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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Per the applicant, children will nap in the living room. Children will nap on cots and mats. Infants will nap in cribs. The applicants understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

The applicants stated that they will provide blankets and sheets and some parents will bring their own. The applicants stated that they will provide diapers, lotion, wipes. The parents will provide formula. Per the applicants a changing pad will be used to change diapers. Applicants stated they will change diapers in the bathroom. LPAs advised the applicants to always supervise at all times infants when changing their diapers.

A records review indicates the applicants completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 9/9/2025. A first aid kit is available at the facility and located in the down stairs walk in closet.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

Only during Covid-19 outbreak, the applicant will receive children at the front door. Per the applicant, upon arrival children’s temperature will be taken, their hands will be sanitized, and the children will be taken to the designated day care area by the applicants. COVID-19 guidelines and precautions were discussed with the applicant.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.
Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.
The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov. Continue Page 5
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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Reporting Requirements:

1.Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2.Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.



No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, which includes but is not limited to the right to enter the home when children are being cared for, interview children and adults, and review documentation.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

H&S 1597.622: 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. The applicant has submitted proof of immunizations.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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The LPA advised the applicants on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure

STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record
Exemption Transfer Request (LCI 9188). Continue Page 7
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269).). A Notice of Site Visit (LIC 9213) must be posted 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Applicants were reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Landlord Consent

APPLICANT OWNS THE HOME

The applicant provided proof of control of property.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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APPLICANTS WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (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 Incidental Medical Services (IMS) - Family Child Care Homes

Review of records to be maintained:

LPA reviewed with applicants 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Safe Sleep

LPA discussed the safe sleep regulations with the applicant 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. LPAs also informed the applicant 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.

Megan’s Law

On this date, 06/19/2023 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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MyChildCarePlan.org

Applicants were informed of the MyChildCarePlan.org site, 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.

Exit Interview


Exit interview conducted and report was reviewed with the applicants Mingqiong Zhang and Hanjie Zhang. Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:

Subscribe to CCLD important information.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.



LPA reminded applicants Mingqiong Zhang and Hanjie Zhang of the Decision and Order
that has been in effect since February 23,2023, and their probation will remain in effect for three years of operating time. Applicants Mingqiong Zhang and Hanjie Zhang will both need to attend an in-person office meeting before a license is issued. The certificates for courses taken in Staffing Child Care Programs and Environmental Safety have been submitted to the Department and are under review with the Department per the Decision and Order.
During the probationary period of 3 years starting from February 23,2023. Applicants Mingqiong Zhang and Hanjie Zhang shall complete a one-hour course related to the operation of their family childcare home every six months. Applicants shall obtain written approval from the Department of the course and submit proof of completion. In the event additional requirements are needed, the applicant will be notified
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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: ZHANG, MINGQIONG & ZHANG, HANJIE
FACILITY NUMBER: 304314181
VISIT DATE: 12/13/2023
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Appeal rights were provided. Exit interview conducted and report was reviewed with the applicants. A license will be issued once all requirements are met.

End of Report
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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