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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334818374
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:02:48 PM

Document Has Been Signed on 09/26/2024 03:02 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:INLAND VINEYARD PRESCHOOLFACILITY NUMBER:
334818374
ADMINISTRATOR/
DIRECTOR:		ANGELA TWYMANFACILITY TYPE:
850
ADDRESS:935 N. MCKINLEYTELEPHONE:
(951) 549-8396
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 133TOTAL ENROLLED CHILDREN: 90CENSUS: 67DATE:
09/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Angela Twyman, DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Elyse Jones conducted an annual inspection. A tour of the inside and outside of the facility was granted and the following was observed and/or noted: Water testing was completed on 12-21-2022
This is not a combination center.
A review of staff and children's records were conducted as part of this evaluation.
· The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization (only if changes have been made)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made)
· The following items have been posted and are updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
- Menu
· The facility is operating with the limits as stated on the license.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 10
Document Has Been Signed on 09/26/2024 03:02 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/26/2024 at 01:14 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(1)(B)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B) Each container shall have an unaltered label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Cited in error
POC Due Date: 09/26/2024
Plan of Correction
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Cited in error
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the facility tour the LPA observed a black trashcan located on the playground that was not leak proof or rodent proof.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands all containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is left on; shall be in good repair; and shall be leakproof and rodent proof. Director agrees to obtain a storage for solid waste that meets Title 22 regulations and submit proof to the Department on or by POC due date of 10-11-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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Document Has Been Signed on 09/26/2024 03:02 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/26/2024 at 01:14 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the staff record review the LPA was unable to review a Mandated Reporter for S4.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands all staff must have a current Mandated Reporter on file when working with children. Director understands training must be taken every two years. Director agrees to obtain a current Mandated Reporter certificate for S4 and submit it to the Department on or by POC due date of 10-11-2024.Training can be completed at www. Manadatedreporterca .com
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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the staff record review the LPA was unable to review current immunization records for S2, S3, S8 and S9.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands all staff must have MMR/DTap/TB prior to working with children and records must be available for review during inspection. Director agrees to obtain immunization records for S2, S3, S8 and S9 then submit a copy to the Department on or by POC due date of 10-11-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 03:02 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/26/2024 at 01:14 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the staff record review the LPA was unable to review an LIC 503 for S8.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands all staff must have an LIC 503 Health Screening completed and on file. Director agrees to have S8 obtain a Health Screening then submit a copy to the Department on or by POC due date of 10-11-2024.
Type B
Section Cited
CCR
101217(a)(1)
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: (1) Employee's full name.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential personal rights risk to the children in care. During the staff record review the LPA was unable to review an LIC 501 for S8.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands all staff must have an LIC 501 Personnel Record on file. Director agrees to have S8 complete a Personnel Record and submit a copy to the Department on or by POC due date of 10-11-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374
VISIT DATE: 09/26/2024
NARRATIVE
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·Ratios are being met during this inspection
· Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards.
· There are no weapons present at the facility as stated by Angie Twyman, Director.
· There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Present for supply drinking water in the indoor activity space
· Medications are stored where inaccessible to children
· Hazards are stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are locked
· All floors shall be clean and safe
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Food preparation area is clean, free of litter, rubbish and free of rodents and other vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Storage containers are not leak and rodent proof.
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· Uncontaminated drinking water shall be readily available both indoors and outdoors and provided by a water delivery service. Personal cups are refilled as needed.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall,
· Sign in/Sign out record was reviewed and meets regulation requirements
· A Staff member is present with current Pediatric CPR/First Aid which expires on 8/2026
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374
VISIT DATE: 09/26/2024
NARRATIVE
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·Opening and closing staff member’s CPR/First Aid expires on 8/2026
· Director completed Health and Safety Training- On File
· A review of children’s records was conducted, and records were found to be complete during this inspection.
· Disaster drills to be conducted every six months- last completed 8-22-2024
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· A review of staff records on 9-26-2024 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
· A review of staff records indicates that all staff present meet minimum qualifications for the position for which they were hired.

LPA discussed the safe sleep regulations with Angie Twyman, 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 Angie Twyman, 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.

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)/ (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
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374
VISIT DATE: 09/26/2024
NARRATIVE
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Angie Twyman, Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200



See LIC809-D for cited deficiencies.

LPA informed Licensee, that this report dated 9-26-2024 documents one Type A citations. Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the safety of children in care. Also, LPA informed the Licensee, to provide an Acknowledgement of Receipt of Licensing Report (LIC 9224), 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 LIC 9224 must be placed in the child's file for verification.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374
VISIT DATE: 09/26/2024
NARRATIVE
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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 platform. 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.

Exit interview conducted and report was reviewed with Angie Twyman, Director.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 09/26/2024 03:02 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/26/2024 at 02:10 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101216.1(b)(1)(A)
101216.1 Teacher Qualifications and Duties
(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below: (1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement specified in (c)(1) below, or shall have obtained a Child Development Assistance Permit issued by the California Commission on Teacher Credentialing. (A) After employment, a teacher hired under (b) above shall complete, with passing grades, at least two units each semester or quarter until the education requirement specified in (c)(1) below is met.
Deficient Practice Statement
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Based on the record review and observation, the Licensee did not meet the above regulation which poses an immediate safety risk to the children in care. During the facility tour LPA observed S7 providing Supervision & Care to children in care as a Lead Teacher. During file review the LPA was unable to review transcripts with required courses for S7. S7 is not currently enrolled in any courses.
POC Due Date: 09/27/2024
Plan of Correction
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Director understands all staff must have required courses to be a Lead Teacher. Records must be on file and available for review. Director agrees to obtain proof of completion of courses for S7. Director also agrees to submit a plan explaining how the class will be covered with qualified staff. Plan is due by close of business on 9-27-2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 09/26/2024 03:02 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/26/2024 at 02:13 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INLAND VINEYARD PRESCHOOL
FACILITY NUMBER: 334818374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(6)
101226 Health-Related Services
(e) In centers where the licensee chooses to handle medications: (6) When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.
Deficient Practice Statement
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Based on the observation, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During review of medication the LPA observed several expired medications for children who were no longer enrolled.
POC Due Date: 10/11/2024
Plan of Correction
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Director understands when a child no longer requires the medication or the child leaves the facility, the medication shall be returned to the Authorized Representative or disposed of. Director agrees to read the regulation and submit a written statement of understanding. The statement should include how the facility plans to remain in compliance in the future. The statement is due on or by POC due date of 10-11-2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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