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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842274
Report Date: 09/22/2022
Date Signed: 09/22/2022 05:38:45 PM

Document Has Been Signed on 09/22/2022 05:38 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:BARRERA HERNANDEZ FAMILY CHILD CARE HOMEFACILITY NUMBER:
334842274
ADMINISTRATOR:LAURA BARRERA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 831-0341
CITY:THOUSAND PALMSSTATE: CAZIP CODE:
92276
CAPACITY: 14TOTAL ENROLLED CHILDREN: 25CENSUS: 3DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Laura Barrera HernandezTIME COMPLETED:
01:15 PM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPAs) Samuel Lopez and Aman Sharma arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday through Sunday, 7:00am to 6:00pm

OFF-LIMIT AREAS INCLUDE: All bedrooms, garage, and side yards

The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are NOT stored inaccessible to children
· Toxins are NOT locked
· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· The facility is a single story home
· Verification of control of property on file (Mortgage payment stub)
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training completed on 6/26/2022
· Pediatric CPR and First Aid Card reviewed was not EMSA approved
· Health & Safety Certificate - completed on 7/11/2013
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274
VISIT DATE: 09/22/2022
NARRATIVE
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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 2/14/2022
· Children’s records are NOT complete
· Employee’s records are complete
· 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

· Resident and/or staff records reviewed on 9/22/2022 indicate that all adults who require caregiver background checks have received all required 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

- LPA discussed the safe sleep regulations with licensee Laura Barrera Hernandez 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 licensee Laura Barrera Hernandez 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274
VISIT DATE: 09/22/2022
NARRATIVE
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- Licensee Laura Barrera Hernandez was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

- 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.



- 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.

LPAs Lopez and Sharma informed licensee Laura Barrera Hernandez that this report dated September 22, 2022 document(s) (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.

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.



Also, LPAs Lopez and Sharma informed the licensee Laura Barrera Hernandez to provide a copy of this licensing report dated September 22, 2022 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.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274
VISIT DATE: 09/22/2022
NARRATIVE
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The LICENSEE, Laura Barrera Hernandez, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee Laura Barrera Hernandez.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/22/2022 05:38 PM - It Cannot Be Edited


Created By: Samuel Lopez On 09/22/2022 at 11:15 AM
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: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed a playhouse in the on-limit area of the backyard with exposed nails and wooden staples protruding from the playhouse as well as chipped wood in various areas around the playhouse. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee agrees to take down the playhouse and submit proof via pictures to Riverside Child Care Regional Office no later than September 23, 2022.
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During the tour of the home, LPAs observed items in restroom such as; shoe cleaner, pet shampoo and vapo bath crystals in the bottom cabinets of the on-limit restroom which is accessible to children in care. Also in the backyard, broken tiles were witnessed to be accessible to daycare children. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee agrees to remove items in restroom as well as tiles in the backyard and make these items inaccessible to children in care. Proof of pictures with a written plan of action explaining how licensee will stay in compliance will be sent to Riverside Child Care Regional Office no later than September 23, 2022.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/22/2022 05:38 PM - It Cannot Be Edited


Created By: Samuel Lopez On 09/22/2022 at 11:15 AM
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: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed Child1(C1) sleeping in a portable bouncing baby seat. According to the warning label, it states "This product is not intended to replace a crib or bassinet for prolonged periods of sleep." This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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During the inspection, licensee removed child from the portable bouncing baby seat and set up a play yard for C1. LPAs explained and discussed infant safe sleep regulations with the licensee. Licensee agrees to submit a written plan as to how she will ensure compliance with the cited regulation section to Riverside Child Care Regional Office no later than September 23, 2022.
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed Child 1(C1) sleeping in a portable bouncing baby seat on top of the dining table in the kitchen area. According to the warning label, it states "Fall Hazard: Babies have suffered skull fractures falling while in and from bouncers. Use bouncer ONLY on floor." This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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During the inspection, licensee removed child from the portable bouncing baby seat and set up a play yard for C1. LPAs explained and discussed infant safe sleep regulations with the licensee. Licensee agrees to submit a written plan as to how she will ensure compliance with the cited regulation section to Riverside Child Care Regional Office no later than September 23, 2022.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/22/2022 05:38 PM - It Cannot Be Edited


Created By: Samuel Lopez On 09/22/2022 at 11:15 AM
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: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. In reviewing facility files, it was observed the last fire drill was conducted on 02/14/2022, which is over the required 6 month period. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee agrees to conduct a fire and/or disaster drill and submit a copy of the log as proof to the Riverside Child Care Regional Office by 09/30/2022.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. It was observed that staff has expired cpr/First Aid certificates and one's on file were not EMSA approved. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee agrees to submit proof of enrollment in an EMSA approved CPR/First aid training to Riverside Child Care Regional Office by September 30, 2022.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/22/2022 05:38 PM - It Cannot Be Edited


Created By: Samuel Lopez On 09/22/2022 at 11:15 AM
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: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing children's files, Child 3(C3) did not have immunization records on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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2
3
4
Licensee agrees to submit proof of immunizations for C3 to Riverside Child Care Regional Office no later than October 6, 2022.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing children's files, Child 2(C2) did not have immunization records on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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2
3
4
Licensee agrees to submit proof of immunizations for C2 to Riverside Child Care Regional Office no later than October 6, 2022.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 09/22/2022 05:38 PM - It Cannot Be Edited


Created By: Samuel Lopez On 09/22/2022 at 11:15 AM
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: BARRERA HERNANDEZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 334842274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. During children's record reviews, Child 1(C1) did not have an LIC 9227, Individual Infant Sleeping Plan on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of Individual Infant Sleeping Plan LIC 9227 for C1 to Riverside Child Care Regional Office no later than September 30, 2022.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. During children's record reviews, Child1(C1) and Child 3(C3)'s files did not include a 15-minute check/infant sleep log or chart. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of immunizations for C3 to Riverside Child Care Regional Office no later than September 30, 2022.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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