342700601-8-2-2022-25-AS-MSEY-CH6NDG-20220810102217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700601
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:52:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211104135340

FACILITY NAME:	OAKMONT OF FAIR OAKS		FACILITY NUMBER:	342700601
ADMINISTRATOR:	CONDIE, NATHAN		FACILITY TYPE:	740
ADDRESS:	8484 MADISON AVENUE		TELEPHONE:	(916) 633-1001
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	0	CENSUS: 82	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Pouya Ansari, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not follow physician's order to change resident's contact lenses
Facility staff did not safeguard resident's personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver compliant findings to a complaint received by the Department on 11/4/2021. LPA met with Pouya Ansari, Executive Director, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

During the course of the investigation, LPA was able to interview (8) current or prior care giver/Med-Tech staff, (1) Health and Services Director and (1) Memory Care Director who worked in Memory Care Unit during the period being investigated, (1) prior Executive Director and resident's (R1) responsible person/Power of Attorney (POA) .LPA attempted to interview an additional (5) caregiver/ Med-Tech staff and a third Health and Services Director, all of whom previously worked at the facility. LPA reviewed documentation pertaining to resident (R1) including, but not limited to: physician’s reports, care assessments, care plans, Medication Administration Records (MAR), letter from resident’s optometrist, physician orders, narrative charting notes and Residence and Services Agreement. The results of the investigation are as follows:

cont on 9099C(1)..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(1) Allegation: Facility staff did not follow physician's order to change resident's contact lenses.
Allegation states that upon admission resident (R1) had a physician's order that he required assistance with replacement of contact lenses on a monthly basis on the 1st of each month. In August of 2020, resident was taken to an optometrist who was appalled by the condition of resident's eyes. Upon removing the eight-month-old contact lenses and replacing them with new lenses, resident exclaimed that he could finally see.

Resident (R1) moved to the Memory Care Unit of the facility on 1/29/20 from a related facility nearby and moved out of the facility on 8/27/2020. Resident's physician report, dated 8/20/2019, noted that resident had a diagnosis of Advanced Dementia and was confused/disoriented and had wandering behavior. The prior physician's report on file, dated 8/3/2017, also noted that resident had a diagnosis of Dementia. Neither Physician's report noted that resident had any visual impairment.

LPA reviewed MAR documentation for months, April, May and July 2019, when resident resided at the related community. July 2019 MAR shows staff initialed on 7/1/2019 as completing the order of changing resident's contact lenses on the first of the month and the start date of the order was entered 6/21/2019. April 2019 MAR and May 2019 MAR also show staff initials confirming that contact lenses were changed on 4/1/2019 and on 5/1/2019, pursuant to an effective order date of 11/22/2018, as it was entered on the MAR. Resident’s care plan, dated 6/29/2019, for a change in condition, includes a note about resident needing reminders to change contact lenses every month; however, no points were allocated to the task of providing reminders. Resident’s care plan 8/15/2019 does not indicate resident has any vision needs. Resident's earlier assessment, dated 7/25/2016, notes that resident uses reading glasses and wears contact lenses.

Resident’s initial assessment at the facility conducted on 1/17/2020 notes that there is no assistance required for vision needs. Documentation reviewed shows resident’s physician’s orders were received and date stamped by the facility on 1/30/2020 and included the order that resident needs assistance with replacement of contacts in each eye on the first of the month only. LPA was provided with a copy of the optometrist’s order regarding staff assisting with changing resident's contacts on a monthly basis. Resident care notes were reviewed from 1/29/2020- 8/26/2020 and there were no notes relating to contact lenses.
cont on 9099C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(2)..
LPA reviewed a letter dated 10/30/2020, from resident's optometrist stating that she has been providing optometry services to resident for over 5 years and that “extended contact lens wear” was prescribed, as requested by resident’s family, as the “most practical plan” for resident due to his memory issues and would prevent resident from losing glasses his glasses and overnight contacts would allow for resident to see at night. The letter states that a contact lenses management plan was sent to the facility with instructions to change resident’s contact lenses monthly using specific eye drops.

The letter states that on 8/17/2020, resident went to see his optometrist for an annual exam and upon examining resident’s eyes, she noticed that “one contact lens was missing and the other one was heavily stained with significant deposits and buildup, indicative of a lens left in the eye much longer than it should have been”. The letter further states that since one contact lens was missing and the other one was stained, resident’s “sight was worse than 20/400, which should significantly affect his daily functions”. The letter states that resident was “visibly elated with his new sight” after a new set of contact lenses was inserted in his eyes. The letter concludes by stating that “failing to follow contact lens protocol can have serious perceivable consequences, ranging from irritation to corneal infections, which could potentially cause blindness if left untreated”.

Interview with one Health and Services Director (S1) stated she “doesn’t recall 100%” if resident wore contact lenses and that the facility would accept a resident in Memory Care who uses contacts, stating "Yes, we would accept them but we would have had to change them and clean them:. Memory Care Director, (S2), who started in May 2020 stated said she was not aware if resident wore contact lenses or if he went to the eye doctor but resident’s POA was upset when she had moved resident out. S2 stated resident's POA sent her an email about getting contacts and she told her that staff can't put contacts in his eyes, due to possible infection, and would need an order, stating "there was not an order on file". Memory Care Director further stated that “The nurse at the time, (S3) checked (R1) eyes and there were no contacts in his eyes". LPA was unable to interview S3 after two attempts were made.

cont on 9099C(3)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(3).. Four (4) additional staff who provided care to resident indicated that they were not sure or didn’t think resident wore contacts. Several other staff who currently work at the facility stated that it would be unusual to have a resident residing in Memory Care who needed assistance with changing contact lenses.

LPA reviewed an email dated 8/18/2020 from resident’s POA to a corporate manager at the facility following their meeting the day before. The email letter references several items that were discussed on 8/17/2020, including reimbursement for a 12-month supply of extended wear contact lenses.

One care staff stated to LPA, "we did not know he had contacts as it was not in his care plan" and (R1) was wearing contacts that were "never changed", The same care staff confirmed that resident's eyes were bothering him and he would rub them and explained "something happened with one eye and he was upset and had issues with his vision and his wife took him to the doctor". Additionally this staff stated she “never saw an order for contacts” for resident but believes there was one.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. In addition, the incident will be further reviewed by the Department to determine if a $500.00 civil penalty is warranted due to resident having vision worse than 20/400 due to contact lenses not being changed monthly.

Allegation: Facility staff did not safeguard resident's personal property.

Allegation states that resident had valuable personal properties stolen while a resident in the facility, namely, $500 worth of coins he collected and his FBI jacket, which is valued at $250.00, that went missing after he received it as a gift on his birthday. Resident was not reimbursed resident for these missing items.

Health and Services Director was asked if she recalls resident having gold coins or rolling gold coins and stated "Very briefly- I recall the coins went missing"- they were a collector type coins - I remember the coins went missing but nothing about the jacket. Prior Memory Care Director (S2) stated she has no recollection of resident having any coins in his room but recalls resident’s POA mentioning that resident would be rolling coins and putting them in the paper rolls. One caregiver said "Yes, he had regular coins wrapped in rolls- he liked rolling them and he also had collector coins that disappeared along with the regular coins. "(R1) was not the only one who had items disappear- we noticed other residents' jewelry disappearing".

cont on 9099C(4)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(4).. A second caregiver stated, when asked if resident had any gold coins “Yes, in his closet by the door, he had 7 rolls of gold coins in paper rolls” and indicated they were viewable if the closet door was opened. This same caregiver indicated she did not hear anything about resident’s coins disappearing. Another caregiver stated she was not aware if resident had gold coins, but she never looked in his closet.

Prior Health and Safety Director, S1, stated she recalls resident having "a windbreaker type of jacket or sweater- it said FBI- it was a basic jacket, nothing fancy". S2 indicated that she only recalls resident having an FBI badge and not a jacket. One caregiver stated that resident had an FBI jacket that disappeared, and another caregiver indicated that resident would wear the same jacket often but she is not sure if it was an FBI jacket. (2) other caregivers stated they were not sure if resident had an FBI jacket and hadn’t heard that it had disappeared. One caregiver staff stated about if resident had an FBI jacket– “Yes, he always used to wear it everyday and then it disappeared. We looked through the laundry and all of Memory CareUnit and it was not found- a staff probably took it".- it was a light-weight jacket, like a windbreaker- when the jacket disappeared, it was brought to management’s attention.”

Neither the FBI jacket or gold coins were declared on the Personal Property and Valuables (LIC621) by POA who also signed a second document, on 1/182020, selecting that she did not wish to inventory resident’s personal property. In the Residence and Service Agreement, page 9, section F(3) ”Responsibility for your Property”, POA initialed. LPA asked POA if the gold coins were disclosed upon move in, and POA stated to LPA "everyone knew he had them and the caregiver saw him rolling coins".

The Facility’s Theft and Loss Policy provides specific information on its policy and procedures for each component, as follows: Inventory, Identification, Security, Documentation of Loss, Notification and Review and Update. Under “Security”, “a locked or secure place for resident’s personal property will be provided” and “Each resident room has a lock on the door” and upon request the facility will install a lock on any cabinet the resident would like to use for safekeeping of valuables.Under “Documentation of Loss” it reads “Loss of personal property with a value of $25 or more will be documented within 72 hours. If the loss exceeds $100, a report will be filed with Law Enforcement agency within 36 hours. An Incident report will be filed with CCL for items that are reported to Law Enforcement. If Oakmont fails to make reasonable efforts to safeguard resident property Oakmont will reimburse the resident for the lost property at the then current value. Reasonable effort will have been demonstrated by evidence of effort to meet each of the requirements specified in Section 87217”.

cont on 9099C(5)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(5)..
House Rules (Appendix E) were included in Residence and Services Agreement which reads, in part, “The Community is not responsible for lost items. We advise you not to keep expensive items in your apartment. You are encouraged to utilize a lockable storage drawer, lockable cupboard, or a safe in your apartment. Valuables such as expensive jewelry, credit cards or cash should not be left in the Community. We strongly recommend that all residents obtain renter’s insurance to protect from any loss or damage to personal property”.

Checked e-faxes- In June 2020, LPA observed incident reports were received for (1) resident missing jewelry and another resident missing cash ($50), credit card and medication from her purse. Both reports indicate that local law enforcement was notified. LPA reviewed the department’s e-fax files for 2020 and did not observe an incident report that was received for resident (R1).

LPA reviewed an email dated 8/18/2020 from resident’s POA to a corporate manager following their meeting the day before. The email letter references several items that were discussed on 8/17/2020, including reimbursement for the coins resident had that went missing from his room. The letter does not mention the FBI jacket. POA confirmed with LPA that resident moved into the facility on/around January 2020 and neither the FBI jacket or gold coins were disclosed and neither the jacket or the gold coins were given to the facility to safeguard.

LPA reviewed the facility's Theft and Loss Record (LIC9060) on 8/2/2022 with the Administrator. LPA observed other entries recorded regarding resident theft/loss but did not observe an entry for resident (R1) regarding his missing jacket and coins. Administrator was unable to locate a completed LIC624 or any other documentation for the missing items and confirmed that an internal investigation was not conducted and a follow up report was not made to law enforcement.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED- California Code of Regulations, (Title 22), is being cited. Failure to correct the deficiencies may also result in civil penalties.

cont on 9099C(6) ...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/11/2022 Section Cited CCR 87465(a)(3)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct training with HSD, care staff and Med-Techs to ensure that all physician orders are not only entered on the MAR but reflected on the care plans also. Submit documentation of training agenda/attendees to the Department by fax by 8/31/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received assistance in changing contact lenses in both eyes every first of each month, beginning on 2/1/2020 through 8/1/2020, while resident resided at the faciltiy, which posed an immediate health and safety risk to residents in care. Resident was seen by his optometrist on 8/17/2020 and it was determined that one contact lense was missing and the second lense was "heavily stained with significant deposits and buildup " causing rseident to have an eye sight worse than 20/400.	8 9 10 11 12 13 14
Type B 08/16/2022 Section Cited CCR 87218(a)(2)	1 2 3 4 5 6 7	87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct training with directors and front line staff to ensure that if there is any theft reported, the proper protocols will be followed. Submit documentation of training agenda/attendees to the Department by fax by 8/31/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure the facility made reasonable efforts to safeguard resident's (R1) property (jacket and coins) when they were reported missing by ensuring each requirement in HSC 1569.153 was met. The facility did not record the lost property in the Theft and Loss Log (LIC9060) and did not report to local law enforcement, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 25-AS-20211104135340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 342700601
	VISIT DATE: 08/02/2022

NARRATIVE

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9099C(6)... Additionally, the complaint alleged there was insufficient staffing to meet the needs of residents although no specifics were provided.

When asked if there were any staffing issues during this time period resident lived at the facility, S1 stated " Occasionally if we had call outs, the Health Services Director or Resident Care Coordinator would work the floor. I don't recall anything outrageous happening like medications being left uncovered."

One caregiver who regularly cared for resident through 6/2020 said: “Yes, some of the time” there was insufficient staffing and sometimes the NOC shift would sleep during their shift. Staff explained she worked 4 days on and 2 days off, never had the same days off, and when she would return from 2 days off, she would notice resident (R1) was wearing the same clothes- the same shirts and stains. She was told other staff would say "he (R1) refused". This staff stated resident (R1)would love his showers and shave and it was very rare if for him to refuse showers.

Another staff stated sometimes the NOC shift wouldn’t show up for work and she would have to stay late to cover. A staff who works in Memory Care unit stated in March 2022 “We've been doing okay- we have 3 total staff , 2 caregivers and 1 med-tech, most of the time”. The current Administrator stated that staffing levels are sufficient at this time with no staffing shortages.

Based on information obtained, the Department was unable to substantiate the allegation of insufficient staffing.

Exit interview conducted and copy of report with appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 8