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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700919
Report Date: 09/30/2025
Date Signed: 09/30/2025 05:19:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250818095041
FACILITY NAME:VITA BELLA ELDERLY CAREFACILITY NUMBER:
342700919
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 594-7250
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:10CENSUS: 10DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Merelisoni MataitogaTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff do not ensure facility is free of pests
Staff does not ensure adequate amounts of food is served to residents in care
Staff does not ensure night supervision is provided to residents
Staff do not prevent residents from entering other residents rooms
Staff did not prevent other staff from consuming residents food
Staff do not ensure adequate supervision is provided to residents
Staff do not ensure reporting requirements are followed
Staff do not ensure meals are properly prepared for residents in care
Staff does not ensure residents are accorded personal privacy
INVESTIGATION FINDINGS:
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On 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to complete and close an investigation into the above allegations. LPA identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA Pang Lee called Licensee, Mark Labella to inform them of the purpose of this visit. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) explained the purpose of this vist.S4 called Licensee in order to review complaint findings with LPA Tamayo but they did not answer.

The census was 10. LPA observed 10 residents and 2 staff.
Based on observations, record review, and interviews, the allegations listed above are SUBSTSANTIATED.

It was alleged that staff did not ensure that staff do not ensure facility is free of pests. Ombudsman (O1) observed live cockroaches on 8/28/25.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250818095041

FACILITY NAME:VITA BELLA ELDERLY CAREFACILITY NUMBER:
342700919
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 594-7250
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:10CENSUS: 10DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Merelisoni MataitogaTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff do not ensure medications are dispensed as prescribed
Staff did not ensure facility had a working water supply for residents in care
Staff does not ensure bathrooms are kept in clean sanitary conditions
Staff do not ensure bathrooms are in good repair
Staff has inappropriate personal conversations while in front of residents
Staff do not seek medical care for residents in a timely manner
Staff discourage residents from filing complaints
Staff do not ensure adequate supervision is provided to residents
INVESTIGATION FINDINGS:
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IOn 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to complete and close an investigation into the above allegations. LPA identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA Lee called Licensee and (P1) contacted them to let them know the purpose of today's visit. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) explained the purpose of this vist.

The census was 10. LPA observed 10 staff and 2 staff.
Based on observations, record review, and interviews, the allegations listed above are UNSUBSTANTIATED.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 09/30/2025
NARRATIVE
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It was alleged staff do not ensure medications are dispensed as prescribed. LPA reviewed medications and MARS and did not observe a preponderance of evidence that medications were not dispensed as prescribed.

It was alleged staff did not ensure facility had a working water supply for residents in care. LPA observed there was working water supply in kitchen and both bathrooms. The facility provides drinking water via refrigerator water dispenser and sometimes provides bottled water. Based on observations and interviews the allegation that the facility does not have a working water supply for residents in care is unsubstantiated.


It was alleged staff does not ensure bathrooms are kept in clean sanitary conditions. Based on observations, the bathroom was in clean condition. LPA observed staff cleaning the bathroom upon arrival on 9/4/2025.

It was alleged staff do not ensure bathrooms are in good repair. Based on observations, the bathroom was in working conditions including the toilet, sink faucet, shower, and doors. There was no corroborating evidence to prove staff do not ensure bathrooms are in good repair.

It was alleged staff has inappropriate personal conversations while in front of residents. Based on resident and staff interviews there was not a preponderance of evidence that staff has inappropriate personal conversations while in front of residents.

It was alleged staff do not seek medical care for residents in a timely manner. Based on records review and interviews, there was no evidence to corroborate that staff do not seek medical care for residents in a timely manner.

It was alleged staff discourage residents from filing complaints. Based on records review and interviews, there was no evidence to corroborate that staff discourage residents from filing complaints.

It was alleged staff do not ensure adequate supervision is provided to residents. LPA observed two staff during each visit. Based on records review and interviews, there was no evidence to corroborate that staff did not ensure adequate supervision is provided to residents

Based on the information gathered through observation and record reviewed, the preponderance of evidence requirement was not met, therefore the above allegations noted were UNSUBSTANTIATED. An exit interview was conducted with S4 and a copy of these LIC 809 reports were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency and to the person responsible... within seven days of the occurrence of ... in (A) through (D).
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Facility will submit a statement of review and understanding of 87211 Reporting Requirements (a) along with providing training for staff regrading reporting requirements by POC due date.
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This requirement was not met as evidenced by staff do not ensure reporting requirements are followed. Record review and interviews timely reporting was not completed when residents have gone to the hospital or emergency care was needed
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Type B
10/10/2025
Section Cited
CCR
87555(b)(1)
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87555 General Food Service Requirements .(b) The following food service requirements shall apply... (1) ... at least three meals per day... (15) hours shall elapse between the third and first meal.
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Facility will review regulation 87555 and create a menu and set meal times along with staff and resident input accounting for preferences and special dietary needs by POC due date. The Facility will also submit written plan on training staff on meal preparation by POC date.
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Staff do not ensure meals are properly prepared for residents in care, as no dinner was prepared on ___ .LPA observed there was not enough food supplies for ten residents in care on 8/22/25,9/4/25,9/8/25, and 9/23/25.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia (b) Licensees shall ... (2) ... ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through... observation to require awake night supervision. ..
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 Facility will submit statement of review and understanding of 87705(b)(2) along with a written plan of correction to ensure one night staff person awake and on duty by POC due date. Training on supervision and dementia will be provided to all current and new staff within the next three weeks and verification will be submitted to licensing once training is completed.
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This requirement was not met as evidenced by staff interviews and record reviews that show there no wake staff at night time and residents with dementia wondering around the facility during day and night time hours, which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
10/10/2025
Section Cited
CCR
7468.1(a)(2)
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7468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment
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Facility will submit a statement of review and understand of 7468.1(a)(2) by POC due date Facility will also reimburse resident for food items purchased in which other residents and staff ate by POC due date.
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This requirement was not met as evidenced by interviewees that reveal that staff consumed residents foods. Staff stated resident, Michelle Fine, purchased three large pizzas on 9/3/25, in which residents and staff had for dinner. Staff admitted no dinner was prepared for residents on 9/3/25, this poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights:(1) To have a reasonable level of Personal privacy
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Facility will provide a written declaration that no facility staff will be trained on care and supervision to ensure residents to not enter other private resident rooms.
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 in accommodations... This requirement was not met as evidenced by LPA observations of residents opening other residents room doors without knocking/permission to do so which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
10/10/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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Facility staff will be trained on care and supervision including redirecting residents with wondering behaviors.
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This requirement was not met as evidenced by staff not preventing residents from entering other residents rooms which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 09/30/2025
NARRATIVE
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LPA observed a live cockroach in the kitchen counter top when reviewing records. LPA observed cockroach traps in bedrooms, bathrooms, and kitchen areas. Staff and resident interviews confirm there are cockroaches in bathrooms and bedrooms which come out at night. Based on the observations of the LPA and review of resident records the allegation the allegation that do not ensure facility is free of pests is substantiated. On 9/30/25 LPAs observed cockroach on the floor located in the dining room. On 9/23/25, LPA Kevin Gould cited deficiency for regulation 87303(a) during a case management visit, in which the facility has agreed to provide a written cleaning and infection control schedule and provide a written plan of correction indicating how the facility will ensure the facility is kept clean.

It was alleged that staff did not ensure that staff does not ensure adequate amounts of food is served to residents in care. LPA toured the kitchen pantry, refrigerator, and freezer inventory and observed. LPA observed there was not sufficient seven day non-perishable and two day perishable food supplies accounting for ten resident’s three meals a day along with utriculus snacks during this visit, on 8/28/25, and 9/4/2025. LPA observed there is no pre-planned menu available to resident’s. The posted sample menu is not followed. LPA observed grocery food deliveries were made on 8/22/25, 8/28/25, 9/4/25, and 9/8/2025, all dates in which Licensing staff and or Ombudsman conducted facility visits. Staff and resident’s stated they think there is not enough food at the facility. Staff stated they did not make dinner on 9/3/25 due to resident ordering and picking up three large pizzas for dinner which they paid for using their personal CalFresh benefits ($53.17) which was given to all residents. The facility Plan of operation states “Menus will offer a variety of dishes, taking into account the cultural and religious background and food habits of the residents … Menus are kept on file in the facility as served … The following menus represent appropriate food groups and portions for our residents … discussion with our residents, this menu may be revised to reflect their individual needs and desires while maintaining a balanced and nutritious diet. At all meals, or anytime, beverages are encouraged and available…”. Based on the observations of the LPA and review of records the staff the allegation that staff do not ensure facility is free of pests is substantiated. On 9/23/25, LPA Kevin Gould cited a deficiency for regulation 87555(b)(26) due to the facility does not have a 2 day perishable food supply to meet the needs of residents which poses an immediate health, safety and personal rights risk to residents in care.

It was alleged that staff does not ensure night supervision is provided to residents. Staff stated there is no wake staff and they are upstairs at night time. Four residents stated R5 wonders around at night. Although R5’s appraisal indicated they do not require nighttime supervision, R5’s LIC 602 physicians report indicated they has is dementia diagnosis, "confused and disoriented sun downing behavior and is at risk"; R5’s LIC 602 is was completed over 12 months ago and is in need of a re-evaluation.

Continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 09/30/2025
NARRATIVE
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Based on the observations of the LPA and review of records the staff allegation that does not ensure night supervision is provided to resident is substantiated.

It was alleged that staff do not prevent residents from entering other residents’ rooms. 5 of 10 residents stated R5 goes into other resident bedrooms. On 9/4/25 and 9/8/25, LPA observed R5 going into other resident bedrooms without knocking first. LPA did not observe any redirection from staff. Based on the observations of the LPA and review of resident records the allegation that Staff do not prevent residents from entering other residents rooms is substantiated.

It was alleged that staff do not ensure reporting requirements are followed. Per record review and interviews, the facility did not submit incident reports (SIR) to the regional office for hospitalization that occurred for R4 on 7/11/25 and 9/1/25 and R3 on 8/29/25. Staff stated they informed R4’s family regarding their high blood pressure and emergency hospital transport being called on 9/1/25 but did not have information regarding the other dates. Based on the observations of the LPA and review of resident records the allegation that Staff do not ensure reporting requirements are followed is substantiated.

It was alleged that staff do not ensure meals are properly prepared for residents in care. 5 out of 10 residents stated there is not enough food and the quality of food is low as of the last 1-2 months. Record review indicates there are special diets that staff is not aware of. Staff stated Menu’s are not created in advance and are decided based on food inventory the day of or the day before. LPA did not see enough food or vegetables available on 9/4/25 and 9/8/25. LPA observed some breads were burnt and served to residents on 9/4/25. On 9/8/25, LPA observed an egg carton containing 60 eggs with a label that read “keep refrigerated” were being stored in room temp pantry. The egg carted was purchased on 9/4/25 from Walmart. Record review shows there has not been any training regarding food preparation for S1, S2, and S4. Based on the observations of the LPA and review of resident records the allegation staff do not ensure meals are properly prepared for residents in care is substantiated.

It was alleged that staff does not ensure residents are accorded personal privacy. 4 out of 10 resents stated R5 opens their door with out knocking often. LPA observed R5 opening the door to R4’s bedroom on 9/4/25. Based on the observations of the LPA and review of resident records the allegation that Staff does not ensure residents are accorded personal privacy is substantiated.
continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 27-AS-20250818095041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 09/30/2025
NARRATIVE
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It was alleged that staff did not prevent other staff from consuming residents food.
S1 admitted they and S2 each ate two slices from the food a resident purchased on 9/3/25 with their personal funds. Based on the observations of the LPA and review of resident records the allegation that staff did not prevent other staff from consuming residents food. is substantiated.

Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTSANTIATED. deficiencies were cited (See LIC809D reports). An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. An exit interview was conducted with S4.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9