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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001843
Report Date: 10/03/2023
Date Signed: 10/03/2023 09:45:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230210141515
FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:CHANTAL S. SALINASFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 14DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director: Janella DouglasTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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- Resident sustained an injury due to staff neglect.
- Staff left hazardous item accessible to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 10/03/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 02/16/2023. LPA met with Executive Director, Janelle Douglas, and explained the purpose of the visit.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, admission agreement, unusual incident/injury report, medical records, personal service plan, care profile, progress notes, temporary service plan wound, and transmission.

Continued page LIC-9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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Allegation: Resident sustained an injury due to staff neglect. – Substantiated.

According to interviews conducted, R1 sustained an injury while in the facility on 02/05/2023. R1 sustained a burn the size of a half dollar on R1’s left leg. The Department received an unusual incident/injury report on 2/12/2023 . Incident report indicated on 02/05/2023 staff were changing R1 prior to bedtime and observed blisters on R1’s left leg from the knee to mid-thigh. Staff provided first-aid and contacted EMT to request an urgent assessment and send out to the hospital. R1’s Power of Attorney (POA) and primary care physician were contacted as well as Executive Director. R1 refused to be transported to the hospital and POA agreed. Although R1’s burn was unwitnessed, interviews with staff and witnesses determined that R1 was burned from an electric fireplace that was located on the floor in the common area of the facility.

On 02/07/2023, R1 was taken to the hospital due to high blood pressure and the burn wound appeared to be at risk for infection. R1 returned to the community the same day with wound care orders and supplies. The facility was to monitor R1 for pain or any signs or symptoms of infection. The facility nurse was to reassess the wound healing progress at 7 and 14 days to ensure proper treatment is being administered. Wound dressing changes were to be performed by Med Techs on shift, all of which had been properly trained on the wound cleanse and dress process. Medical records indicated that the R1’s burns were second and first degree burns to lateral left lower leg, knee, and thigh. At the time of R1’s hospital visit on 02/07/2023, burn did not show signs of infection and R1 is stable for discharge back to memory care facility. On 2/08/2023, R1 returned to the hospital concerning burn care. The hospital provided R1 with bacitracin, gauze, and nonadherent and tape and R1 returned to the community. On 2/13/2023, R1 returned to the hospital for re-evaluation of burn wounds. R1 diagnosed with third degree burn on left leg and will require daily wound care. R1 was discharged from the hospital and admitted to skilled nursing facility on 2/15/2023.

R1 was admitted into the facility on 10/12/2021. The Department requested and reviewed R1’s physician’s report that was completed on 09/15/2021. According to R1’s physician’s report, R1’s primary diagnosis is progressive supranuclear palsy (PSP) and secondary diagnosis is dementia and Parkinson's. R1 cannot manage their own treatment, medication, and equipment. R1 has visual impairment, bowel impairment, bladder impairment, and motor impairment/paralysis. R1 uses an assistive device such as a walker and cannot walk unassisted. R1 is confused/disoriented and cannot locate self temporally or spatially. R1 has wandering behavior and is not able to leave the facility unassisted. R1 is non-ambulatory based upon both physical and mental condition. Facility completed R1’s personal service plan on 10/09/2021.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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According to R1’s service plan, R1’s PSP condition causes balance with balance, movement, coordination. R1 shuffles when R1 walks. Facility is to provide escort services and encourage and re-direct R1 to use walker. R1 requires physical assistance related to the inability to stand independently during dressing or grooming tasks, and bathroom tasks. R1 is independent going to and from the dining room or community activities. R1 can transfer self and needs standby assist occasionally. Care staff is to monitor R1’s gait and balance.

The Department determined that although R1’s injuries were not a direct result of staff neglect, facility staff did however neglect to provide a safe environment and did not ensure that the electric fireplace was inaccessible to residents with a diagnosis of Dementia.

Allegation: Staff left hazardous item accessible to residents in care. – Substantiated.

According to interviews conducted, staff reported that that R1 was sitting too close to an electric fireplace which was located on the ground in the common area of the facility. This facility services residents with a diagnosis of Dementia and therefore must ensure that any items that could constitute danger to residents should be inaccessible. At the time of the incident, R1 was wearing shorts. On 2/5/2023, LPA Keosavang arrived at the facility unannounced to open complaint investigation. LPA met with Executive Director, Morgan Greenwood Whinery, and explained the purpose of the visit. LPA discussed allegations with ED and toured the facility with ED. ED indicated R1 was recently sent to the hospital due to an injury. ED indicated an unusual incident report was submitted to CCLD for review. A care staff had observed R1 with blisters on R1’s left leg during a change prior to bedtime. It was determined that R1 was injured due to a portable electric fireplace located in the common area. R1 was assessed by EMT and was recommended to be transferred to the hospital, however, R1 refused. Facility notified R1’s POA. LPA Keosavang observed the electric fireplace located in the common area of the facility. LPA observed the electric fireplace to be unplugged but still accessible to residents in care. ED pointed out that the facility had disconnected the wire on the electric fireplace so it cannot be connected to an outlet. ED stated electric fireplace will not be used moving forward. The Department interviewed a total of three (3) facility staff. Interview statements received from staff indicated that R1 had a habit of sitting close to the fireplace and moving around in their wheelchair.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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Based on interviews and observations, the facility did not ensure residents had a safe living environment by resident’s having access to an electric heater. The Department finds the above allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Failure to correct the deficiencies may also result in civil penalties.

Appeal rights provided.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
87705(f)(1)
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87705(f)(1) Care of Personal with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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The facility agrees to remove electric fireplace from the common area and submit a statement of understanding and compliance to CCL via email by POC due date, 10/04/2023.

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This requirement is not met as evidenced by: Based on records review, observation, and interviews, electric fireplace located in common area was accessible to residents in care causing R1's injuries. This poses an immediate health, safety, and personal rights violation to residents in care.
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Type A
10/04/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The facility agrees to review regulation section 87468.1 and submit a letter of understanding to CCL via email by POC due date, 10/04/2023.
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This requirement is not met as evidenced by: Based on records review, observation, and interviews, the facility did not ensure that electric fireplace was inaccessible to residents in care. This poses an immediate health, safety, and personal rights violation to residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Sarena Keosavang
COMPLAINT CONTROL NUMBER: 25-AS-20230210141515

FACILITY NAME:BROOKDALE ROSEVILLEFACILITY NUMBER:
315001843
ADMINISTRATOR:CHANTAL S. SALINASFACILITY TYPE:
740
ADDRESS:1 SOMER RIDGE DRTELEPHONE:
(916) 773-5955
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:40CENSUS: 14DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director: Janella DouglasTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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- Staff did not care for resident's wound in a sanitary manner.
- Staff did not ensure resident had clean laundry.
- Staff did not ensure that resident was adequately fed.
- Staff did not ensure resident's hygiene needs were met.
- Staff did not keep the facility clean and sanitary.
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 10/03/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 02/16/2023. LPA met with Executive Director, Janelle Douglas, and explained the purpose of the visit.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, admission agreement, unusual incident/injury report, medical records, personal service plan, care profile, progress notes, temporary service plan wound, and transmission.

Continued page LIC-9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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Allegation: Staff did not care for resident's wound in a sanitary manner. – Unsubstantiated.

According to complainant, R1 had multiple burns. On 02/9/2023, complainant observed staff same in to R1’s room to treat the wound during the visit and laid the gauze and scissors on the dirty floor. Staff was wrapping R1’s injuries with dirty supplies.

The Department interviewed a total of two (2) facility staff. S1 indicated the direction for the after care for R1’s burn is to keep the burn clean and dry. Staff is to dress R1 in shorts to ensure there was no irritation and it was easier to change the bandage for the burn. S1 indicated caregivers did not change R1’s wound and it was the responsibility of the nurse and Med Tech.

On 8/10/2023, LPA Keosavang arrived at the facility to conduct complaint investigation. LPA requested to interview the nurse and Med Tech. According to Operational Specialist, Sharon Monck, nurse, and the Med Tech that provided wound after care is no longer working at the facility. The facility provided Med Tech’s contact information. On 8/25/2023, LPA called Med Tech and left a detailed message. LPA requested for Med Tech tor turn LPA’s call. LPA unable to receive interview statement from Med Tech.

Allegation: Staff did not ensure resident had clean laundry. – Unsubstantiated.

On 2/9/2023, complainant observed R1 not wearing shows. Socks that R1 was wearing were wet from something that R1 had been drinking spilling on R1’s feet.

According to R1’s personal service plan, R1’s laundry days are Wednesday and Saturday. Staff is to assist R1 with the set-up, selection or laying out of clothes. R1 can perform the following tasks with physical assistance as needed, putting on/taking off clothing, socks, and shoes.

On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, caregivers in the morning shift are responsible for residents’ laundry. Caregivers are to check residents’ laundry basket every morning to see if they are full or not. Residents have their scheduled laundry days and if caregivers observed laundry baskets are full, they will make sure to do the residents laundry. S1 explained R1 did not have a lot of clothes so staff had to wash R1’s clothes more frequently compared to other residents in care. Housekeeper will also assist with laundry if needed. Interview statement received from S2 indicated, housekeeper assist with laundry, but it is the caregiver’s responsibility. S2 stated when caregivers see that residents’ laundry basket is full, they would do it right away or on their scheduled days. S2 stated if a resident in care had an incident caregiver would change out the sheets right away and throw it in the washer and dryer.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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Allegation: Staff did not ensure that resident was adequately fed. – Unsubstantiated.

On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. Complainant is concern with the amount of food R1’s eating in R1’s condition. R1 does not have use of both arms and struggling to eat due to Dementia. Complainant stated is concern that R1 was losing weight since R1 moved into the facility.

According to R1’s personal service plan, R1 is on a regular diet. R1’s food is to be cut up in the kitchen. On 2/15/2023, LPA conducted a tour of the facility with Executive Director, Morgan Greenwood Whinery. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days.

On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was on a regular diet. S2 stated there is plenty of food at the facility to feed all the residents in care.

Allegation: Staff did not ensure resident's hygiene needs were met. – Unsubstantiated.

On 2/9/2023, complainant observed R1’s wheelchair was covered with food. Staff did not wipe R1’s hands after R1 ate a piece of chocolate cake with chocolate syrup. Staff don’t keep the facility clean, and the floors are covered with food. According to R1’s personal service plan, R1 schedule showers days are Monday and Friday between 7am and 8am. On 8/10/2023, LPA Keosavang arrived at the facility unannounced to conduct complaint investigation. LPA interviewed a total of two (2) staff. Interview statement received from S1 indicated, R1 was able to feed self. S1 explained R1 would “make a big mess” when eating due to R1’s diagnosis. S1 stated when R1 would make a big mess when eating caregivers would take R1 back to R1’s room and wash/clean R1 and bring R1 back out to the common areas. Caregivers would assist R1 daily with brushing teeth, washing face, and showers on schedule days. Interview statement received from S2 indicated, R1 gets dirty when eating. S2 explained when R1 is finished eating caregiver would clean R1 right away. “They don’t leave him dirty.” S1 stated R1 is scheduled for showers two days a week and as needed if there are accidents.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 25-AS-20230210141515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE ROSEVILLE
FACILITY NUMBER: 315001843
VISIT DATE: 10/03/2023
NARRATIVE
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Allegation: Staff did not keep the facility clean and sanitary. – Unsubstantiated.

On 2/15/2023, LPA Keosavang arrived at the facility unannounced and met with Executive Director, Morgan Greenwood Whinery. LPA toured the facility with ED. LPA observed common areas, courtyard, kitchen, medication room, and five (5) residents’ bedrooms and bathrooms. LPA observed the facility to be clean and sanitary.

The Department has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.



An exit interview was conducted, and a copy of this report will be provided to the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9