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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370750
Report Date: 02/17/2023
Date Signed: 02/17/2023 04:48:07 PM

Document Has Been Signed on 02/17/2023 04:48 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:DOVE CANYON MONTESSORI SCHOOLFACILITY NUMBER:
304370750
ADMINISTRATOR:ZADEH, ATOSAFACILITY TYPE:
850
ADDRESS:31971 DOVE CANYON DRIVETELEPHONE:
(949) 589-4501
CITY:TRABUCO CANYONSTATE: CAZIP CODE:
92679
CAPACITY: 72TOTAL ENROLLED CHILDREN: 41CENSUS: 27DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Atosa ZadehTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA), Thompson conducted an onsite inspection for the purpose of an Annual Random. LPA and Director Atosa Zadeh toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 15 preschool age children and 12 toddlers with 3 staff. Facility hours are Monday through Friday, 7 AM to 6 PM.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions with the exception of Somayeh Omidi. LPA observed Somayeh caring for 12 children along with another staff present inside the toddler classroom. Director stated Somayeh is a volunteer. Somayeh stated she is a volunteer who has been present for 5 months and volunteers 25-26 hours a week sometimes. LPA reviewed Somayeh file and observed Somayeh is a paid employee that has a sign form that reads "I have read and agree to the terms and conditions of employment as set forth." LPA also reviewed a sign copy of the employee rights form LIC 9052 and Employment Agreement form that shows Somayeh is a paid employee.

During the inspection of the indoor activity space, LPA observed comet with bleach inside an unlocked cabinet located under the faucet inside the toddler classroom. LPA observed staff (S1) remove the comet from the cabinet and walked out the classroom. There is drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges.

The facility has not conducted an emergency drill within the past six months, last fire/disaster drill was documented on 11/05/21. As LPA was taking a picture of the documentation, Director changed the year to 2022 with a pen. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750
VISIT DATE: 02/17/2023
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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. LPA observed a shed with the doors closed but unlocked with numerous cans of paint and Minwax Stain & Polyurethane. The shed is located on the preschool play yard. Director was advised to remove any items inside the shed that can be hazardous to children or place a lock on the shed. LPA also observed an inclined wading pool with water approximately 1 feet in height on the preschool play yard. A play house located at the far end of the play yard (East) was observed to have nails exposed. Director was advised to remove the structure or have repairs made so that it is not a hazard to children in care.

Staff files were reviewed for staff present during the facility inspection this date; 3 staff files were reviewed. Health screening and immunization's as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Two staff associates present inside toddler classroom did not have immunization records available at the time of visit.

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director and staff did not have a current mandated reporter certification available for review. Director present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 02/2024.

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 documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed 2 out of 5 children’s files were found to be incomplete. Child (C1) was missing the following forms; Identification and Emergency Information, Physicians Report, Consent for Emergency Medical Treatment, Notification of Parent Rights and Personal Rights. Child (C1) and Child (C2) were missing immunization records.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750
VISIT DATE: 02/17/2023
NARRATIVE
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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 www.ccld.ca.gov 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

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 Planhas 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

LPA discussed the safe sleep regulations with director 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 director 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.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750
VISIT DATE: 02/17/2023
NARRATIVE
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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.

In the areas that were evaluated, four Type A and 5 Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. Staff Records - Type A: 101170(e)(2), Physical Plant - Type A: 101238(g), Physical Plant - Type A: 101238(g)(1), Physical Plant - Type A: 101238.5(a)(1), Physical Plant - Type B: 101174(d), Staff Records - Type B: 1596.7995(a)(1), Staff Records - Type B: 1596.8662(b)(1), Children Records - Type B: 101220.1(a), and Children Records - Type B: 101221(a).

LPA Thompson informed Director Atosa Zadeh that this report dated 2/17/2023 document(s) four (4) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Thompson informed the Director to provide a copy of this licensing report dated 2/17/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Atosa Zadeh. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights and deficiencies 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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Page: 2 of 9
Document Has Been Signed on 02/17/2023 04:48 PM - It Cannot Be Edited


Created By: Dean Thompson On 02/17/2023 at 03:09 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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed comet with bleach inside an unlocked cabinet located beneath the sink inside the toddler classroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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LPA observed staff (S1) remove the comet from the cabinet.
Type A
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed a shed with the doors closed but unlocked with numerous cans of paint and Minwax Stain & Polyurethane which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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3
4
Director was advised to remove the any items inside the shed that can be hazardous to children or place a lock on the shed and send prrof 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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 02/17/2023 04:48 PM - It Cannot Be Edited


Created By: Dean Thompson On 02/17/2023 at 03:09 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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238.5(a)(1)
Wading Pools
(a) Notwithstanding the requirements of Section 101238(e), fencing is not required for inflatable or other portable plastic wading pools with sides low enough for children using the pool(s) to step out unassisted. (1)These pools shall be emptied after each use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA also observed a wading pool with water approximately 1 feet in height on the preschool play yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Director agreed to drain the water from the pool and send proof to LPA by POC due.
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions with the exception of Somayeh Omidi. LPA observed Somayeh caring for 15 children along with another staff present which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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2
3
4
Director agreed to Request a transfer of a criminal record clearance for Somayeh Omidi 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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 02/17/2023 04:48 PM - It Cannot Be Edited


Created By: Dean Thompson On 02/17/2023 at 03:09 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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility has not conducted an emergency drill within the past six months, last fire/disaster drill was documented on 11/05/21 which poses/posed 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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3
4
Director agreed to conduct and document a fire/disaster drill and submit proof to LPA via email or mail.
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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Two staff associates present inside the toddler classroom did not have immunization records available at the time of visit which poses/posed 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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2
3
4
Director agreed to provide proof of immunization records for Staff S1 and Staff S2 by POC due date via email or mail.
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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 02/17/2023 04:48 PM - It Cannot Be Edited


Created By: Dean Thompson On 02/17/2023 at 03:09 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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

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) (record review)], the licensee did not comply with the section cited above. Director and staff did not have a current mandated reporter certification available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
1
2
3
4
Director agreed to submit mandated reporter certification to LPA by POC due date via email or mail.

www.mandatedreporterca.com
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Child (C1) and Child (C2) were missing immunization records from their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
1
2
3
4
Director agreed to submit proof of immunization record for C1 and C2 by POC due date via email or mail.
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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 02/17/2023 04:48 PM - It Cannot Be Edited


Created By: Dean Thompson On 02/17/2023 at 03:09 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: DOVE CANYON MONTESSORI SCHOOL
FACILITY NUMBER: 304370750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Child (C1) was missing the following forms; Identification and Emergency Information, Physicians Report, Consent for Emergency Medical Treatment, Notification of Parent Rights and Personal Rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
1
2
3
4
Director agreed to submit a completed file for Child (C1) by POC due date via email or mail.
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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
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