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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846269
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:23:33 PM

Document Has Been Signed on 02/28/2025 04:23 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:JIMENEZ BARRAGAN FAMILY CHILD CAREFACILITY NUMBER:
334846269
ADMINISTRATOR/
DIRECTOR:		JIMENEZ BARRAGAN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 973-3418
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
02/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Maria Jimenez, facility representativeTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 2/28/2025 at 1:00 PM, Licensing Program Analyst (LPA) Claudia Caywood arrived at the facility to conduct a required three-year inspection as part of a compliance review. Licensee was absent during this visit. Facility representative, Maria Jimenez was left alone with a total of 12 children. 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 Friday, 6:00am to 5:00pm

OFF-LIMIT AREAS INCLUDE: Entire second floor, kitchen, laundry room, side yard, and garage.



The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision was not provided during this inspection (See 809-D)
· 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 inaccessible to children
· Toxins were locked
· There are no weapons present at the facility. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· The facility is a second story home
· Stairs are barricaded
· Verification of control of property on file- (Lease Agreement)
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted (See 809-D)
· Mandated Reporter Training was completed on 7/15/2022
· Pediatric CPR and First Aid Card expired on 6/2024
· Health & Safety Certificate - completed on 7/24/2022 (CONT. 809-C)
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Claudia Caywood
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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 9
Document Has Been Signed on 02/28/2025 04:23 PM - It Cannot Be Edited


Created By: Claudia Caywood On 02/28/2025 at 02:48 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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that licensee did not have a pool alarm for LPA to inspect during annual inspection which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to purchase a pool alarm in accordance with PIN 25-01-CCP by the POC due date of 3/28/25. Licensee will email LPA a video of the alarm to go off while in the pool.
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that they did not have a life ring for LPA to inspect that is complaint with PIC 25-01-CCP which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to purchase a life ring 17 inches in diameter and approved by the US Coast Guard in accordance with PIN 25-01-CCP by the POC due date of 3/28/25. Licensee will email LPA a video of the alarm going off while in the pool.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Claudia Caywood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


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Document Has Been Signed on 02/28/2025 04:23 PM - It Cannot Be Edited


Created By: Claudia Caywood On 02/28/2025 at 02:48 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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that licensee did not have a body hook in accordance with PIN 25-01-CCP posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide LPA a receipt showing purchase of body hook by the POC due date 3/28/25
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that they did not log an inspection per PIN 25-01-CCP which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide LPA a copy of their pool safety log per PIN 25-01-CCP by the POC due date of 3/28/2025 via email.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Claudia Caywood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 02/28/2025 04:23 PM - It Cannot Be Edited


Created By: Claudia Caywood On 02/28/2025 at 02:48 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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that they did not keep a sleep log for infant in care which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide the LPA a copy of a month's worth of a sleep log for infant list on LIC 857 by the POC due date of 3/28/25
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 interview and record review, the licensee did not comply with the section cited above in that licensee and assistant did not have a current mandated reporter for the LPA to review which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide the LPA a current mandated reporter certificate for licensee and assistnt by the POC due date of 3/28/25
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:Gilbert Sena
LICENSING EVALUATOR NAME:Claudia Caywood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 02/28/2025 04:23 PM - It Cannot Be Edited


Created By: Claudia Caywood On 02/28/2025 at 02:48 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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and record review, the licensee did not comply with the section cited above in tht they did not have a current CPR & First Aid certificate for the LPA to review which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide proof of CPR & First Aid certificate for licensee and assistant by thte POC due date of 3/28/25
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that the licensee did not have a PUB 394- Parent's Rights Poster posted in a prominent location which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide a photo of the PUB 394 posted in a prominent location and email to LPA by POC due date of 3/28/2025
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:Gilbert Sena
LICENSING EVALUATOR NAME:Claudia Caywood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 02/28/2025 04:23 PM - It Cannot Be Edited


Created By: Claudia Caywood On 02/28/2025 at 02:48 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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in the licensee was missing a file with required documentation for an infant in care which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee is to provide proof of documentation for the infant child via email to LPA by POC due date of 3/28/25.
Type B
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the assistant was left alone with 12 children and put her out of ratio which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee agreed to provide a written statement of acknowledgement citing the above California Code of Regulation section 102416.5 (e) sign and dated by licensee and assistant byt the POC due date of 3/28/25
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:Gilbert Sena
LICENSING EVALUATOR NAME:Claudia Caywood
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


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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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269
VISIT DATE: 02/28/2025
NARRATIVE
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There are bodies of water currently. LPA observed a pool/jacuzzi with a self-closing and self-latching gate that was tested by LPA. The gate is a minimum of 60 inches and pool is compliant with AB2866. Licensee did not comply with PIN 25-01-CCP swimming pool safety licensing requirement for AB2866 (See LIC 809-D) 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, safe, and age-appropriate toys
· Current roster on file
· Documentation of fire and disaster drills completed on: 10/16/2024
· Children’s records are not 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 2/24/2025 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 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 [or facility representative] 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.

LPA also informed facility representative 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. (CONT. 809-C)

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Claudia Caywood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
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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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269
VISIT DATE: 02/28/2025
NARRATIVE
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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: https://www.ada.gov/resources/child-care-centers/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

The licensee provided proof of control of property.

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.

On this date, 2/28/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. (CONT. 809-C)
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Claudia Caywood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
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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: JIMENEZ BARRAGAN FAMILY CHILD CARE
FACILITY NUMBER: 334846269
VISIT DATE: 02/28/2025
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

LPA reviewed with facility representative the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

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

Cited deficiencies during this inspection.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the Facility representative, Maria Jimenez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the facility representative, Maria Jimenez.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Claudia Caywood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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