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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881149
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:54:18 PM

Document Has Been Signed on 09/25/2024 04:54 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIVINE RESIDENTIAL HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR/
DIRECTOR:		SOLOMON OLOWOFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 571-1799
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 2DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Solomon OlowoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 09/25/2024 at 1:00 PM, Licensing Program Analysts (LPA) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Brown and Hernandez were greeted by a staff and gained access at the home. Administrator Solomon Olowo was contacted and informed of the visit. LPAs Brown and Hernandez explained the purpose of the visit to House Manager Olayinka King. The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Hernandez completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) audit and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Hernandez observed two (2) clients during the inspection. There is a capacity of four (4). The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs Brown and Hernandez inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Hernandez inspected client bathrooms. LPAs observed hot water temperature to be at 135 degrees. Deficiency will be issued. LPAs observed common towels located in the kitchen. Technical violation will be issued. The facility is equipped with operational smoke detectors and a charged fire extinguisher. LPAs observed first aid kit but no first aid book. Deficiency will be issued.



Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Hernandez observed no night lights at the hallway leading to clients' shared bathrooms.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149
VISIT DATE: 09/25/2024
NARRATIVE
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**Continuation from LIC809**
Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached three (3) car garage observed. However, LPAs observed detached wood fence with multiple sharp and rusted nails on left side of facility and broken glass bottle on right side of the facility. Deficiency will be issued. Also, LPAs observed multiple gallons of paint and gasoline in outside shed unlocked and accessible to clients in care. Deficiency will be issued.

Food Service: LPAs Brown and Hernandez observed two (2) day(s) supply of perishable food and seven (7) day non-perishable foods.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.


Record Review: LPAs Brown and Hernandez reviewed two (2) client files for admission agreements, medical assessments/physician reports, centrally stored medication list, and Individual Program Plan (IPP). LPAs observed no completed admission agreement for Client #2 (C2) as evidence of no signature of facility representative in C2's admission agreement. Deficiency will be issued. LPAs Brown and Hernandez also reviewed staff and administrator's file for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs observed Staff #2 (S2) does not have the required training and first aid from persons qualified by agencies including but not limited to the American Red Cross. Deficiency will be issued. Also, LPAs observed Staff 2 (S2) does not have a completed Tuberculosis (TB) test with TB test result maintained in S2's file as evidence of no physician signature and signature date. Deficiency will be issued.

LPA Brown and Hernandez audited two (2) clients’ medications. LPAs observed that one (1) medication of Client #1 (C1) was not given per C1's physician order. Deficiency will be issued. LPAs Brown and Hernandez audited two (2) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed, and copies were provided to Administrator Solomon Olowo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 11 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 by not ensuring that outdoor passageway and other areas of potential hazards were free of obstruction, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to submit proof to LPA Hernandez of side gate with no sharp objects and backyard free of broken glass bottles by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by not ensuring that chemicals underneath kitchen sink and upper loft were inacessible to clients in care, iwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee removed toilet bowl cleaner chemical and dust chemical remover during the visit and stated train to staff of this regulation 80087(g) and submit proof 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons 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 by not ensuring that disinfectants, cleaning solutions and poisons were inacessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to lock the shed and submit proof to LPA Hernandez by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 by not ensuring that hot water temperautre was not less than 105 degrees and not more than 120 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to submit proof of water temperature testing between 105 and 120 degress to LPA Hernandez 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 by not ensuring that Staff #2 (S2) completed the required health screening record, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to submit proof of completed health screening report for Staff #2 (S2) by Plan of Correction due date.
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

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 by not ensuring that S2 completed the required Tuburcluosis (TB) test and test result, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to submit proof of a completed Tuberculosis (TB) test with TB test result for S2 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 by not ensuring that Staff #2 (S2) has the required first aid/CPR certification, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to submit proof of S2's enrollment or proof of completed certification of First aid/CPR to LPA Hernandez by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 by not ensuring that one (1) medication of Client #1 (C1) was given per C1's doctors directions, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b) and submit proof to LPA Hernandez 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 by not ensuring that stove exhaust fan are clean and chair and microwave are in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee stated to clean stove exhaust fan and remove microwave or purchase new one along with seat cover for chair and submit proof to LPA Hernandez by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

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 by having a mattress in upstairs loft, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee stated to remove mattress from upstairs loft and submit proof to LPA Hernandez 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 by not ensuring night lights are maintained in hallways and passages to nonprivate bathrooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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2
3
4
Licensee stated to submit purchase or obtain night lights and submit proof to LPA Hernandez by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

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 by not ensuring that Client #2 (C2) has a completed admission agreement as evidence of no signature of facility representative observed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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2
3
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Licensee stated to submit a completed copy of admission agreement for C2 to LPA Hernandez 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 09/25/2024 04:54 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/25/2024 at 03:10 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(g)(1)(A)
80075 Health Related Services
(g) If the facility has no medical unit on grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. (1) The supplies shall include at least the following:
(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

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 by not ensuring facility had a current first aid manual book, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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2
3
4
Licensee stated to submit proof of purchase of first aid book to LPA Hernandez by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 10 of 11