304314222-9-8-2023-06-CC-VTRH-CVGPSH-20230908113422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314222
Report Date: 09/08/2023
Date Signed: 09/08/2023 11:34:47 AM

Document Has Been Signed on 09/08/2023 11:34 AM - 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:	DADON, KEREN		FACILITY NUMBER:	304314222
ADMINISTRATOR:	DADON, KEREN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 545-3771
CITY:	IRVINE	STATE: CA	ZIP CODE:	92614
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	09/08/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Dadon, Keren Applicant.		TIME COMPLETED:	12:00 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	Page 1 On 9/8/2023, Licensing Program Analyst (LPA) V Trinh conducted an announced, in-person Pre-Licensing inspection for a new Large Family Child Care home. The LPA met with applicant Dadon, Keren who provided a tour of the home. A review of the Facility Personnel Report Summary indicates two adults live in the home. The adult resident(s) received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are two minors living in the home. The applicant stated that she is not registered with any Resource Foster Care agency and that she does not hold a Resource foster parent license. The applicant was reminded to notify the licensing office of any changes. The applicant is requesting a Large Family Childcare Home license. Per the applicant, operation hours will be Monday through Friday, 8:00 AM- 4:30 PM. Care and supervision will be provided to children ages newborn to 14 years old (infants). 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 two-story home with 5 bedrooms totals, 2 downstairs 3 up stairs, 4 bathrooms totals, 2 downstairs, and 2 upstairs, a living room, main floor room, a kitchen, 1 office room down stair, a laundry room, a front yard (not fenced), a backyard with fenced, and a garage. There is no fireplace. There are stairs barricaded by a child proof safety gate. Continuous page 2

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated identify the entire area. Example entire 2^nd floor, 2 bedrooms on the 1^st floor, 1 office room (1^st floor), 1 bathroom in the first floor on the back of the slide door, a kitchen, front yard, and garage the off-limits areas. The applicant has a child-proof safety gate at the bottom of the stairs to the 2^nd floor, ensuring the 2^nd floor is inaccessible to children in care. The applicant status will be put the Safety separation slide all the time when operation hours. Applicant status the slide door on the back of the main room leading to the room 1 bedroom will be close with the door latch. Applicant status the door leading to the kitchen will be close with key lock when daycare operation hours. Garage ensuring this area is inaccessible to the children in care.
The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.
Areas Designated for Day Care Activities: The applicant has designated the main room, and a bathroom is located to the right side of the entrance for day-care children . Each of infant will nap in the Crib/play pen and will be located in a main room . Preschool children will nap in the main room.

Garage will not be used for day-care. The applicant stated the garage will be off-limit.

Garage is to be utilized for limited activities, day-care children are not to napped or eat in the Garage.
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 a small step tool 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 LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).
Cont page 3

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed. Smoke and carbon monoxide detectors were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed (location of the distinguisher).

This facility has no pet.

OUTDOOR PLAY AREA:
Outdoor/ Backyard is Off-limit to day care children. Applicant status will take children to the park every week, and applicant status will be 100 percents supervision children at the San Carlo Park.

The applicant stated she will provide food (lunch) for the children. Applicant status parents will bring snacks. 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.

Per the applicant, children will nap in the 5 Liliano Irvine, Ca 92614. Children will nap on cots/mats and infants in cribs/play yards. The licensee 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 applicant stated that parents will provide linens and blankets for napping. The applicant stated that parents will provide diapers, lotion, wipes, and formula for the infants. Per the applicant, a changing table will be used to change diapers. Document where the changing table is located LPA advised the applicant to always supervise at all times infants when changing their diapers.

A records review indicates the applicant 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 8/27/2023. A first aid kit is available at the facility in the kitchen.

Cont page 4

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 3 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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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 applicant. 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.

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.

Cont page 5

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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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.
The LPA advised the applicant(s) 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).
Cont page 6

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 5 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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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.

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).

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 for 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.
Cont page 7

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 6 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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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

[Applicant, Licensee, or Facility representative] was 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 OR RENTS/LEASES THE HOME:

The Dadon, Keren provided proof of control of property.

APPLICANT RENTS/LEASES THE HOME AND HAS LANDLORD CONSENT:

Because the [applicant, or licensee] rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Incidental Medical Services Plan (IMS

APPLICANT KNOWS PROSPECTIVE CLIENTS WILL NEED IMS:

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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.

cont page 8

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

NARRATIVE

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Review of records to be maintained:

LPA reviewed with [applicant, licensee, or facility representative] the LIC 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, 7/06/2023, 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.

MyChildCarePlan.org

[Applicant, or Licensee] was 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.

Notice of Site Visit

A notice of site visit was given to [applicant, licensee or facility representative] and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Cont page 9

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 8 of 9

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: DADON, KEREN	FACILITY NUMBER: 304314222
	VISIT DATE: 09/08/2023

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Exit Interview
Exit interview conducted and report was reviewed with the [applicant, licensee, or facility representative]. Please include their name. 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.

The Small/Large Family Child Care Home was not in compliance with Title 22 Regulations at the time of inspection. The applicant is required to submit the following corrections to the licensing office by the due date of DATE.

1. Applicant will take a CPR and First Aid with American Red Cross or EMSA.
2. Mats for children

3. Pictures of the entire house when you put the Safety separation slide door together.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.

Appeal rights were provided. Exit interview conducted and report was reviewed with the [applicant, licensee, or facility representative] Dadon, Keren

End of Report .

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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