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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701213
Report Date: 07/01/2026
Date Signed: 07/01/2026 07:07:22 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
04/16/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250416092323
FACILITY NAME:CARLTON SENIOR LIVING SACRAMENTOFACILITY NUMBER:
342701213
ADMINISTRATOR:WIMMER, KASIEFACILITY TYPE:
740
ADDRESS:1075 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:185CENSUS: 128DATE:
07/01/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kasie Wimmer, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure residents hearing aides are charged.
Staff are not following incontinent care plan for resident.
Staff are not ensuring that resident laundry is being cleaned and returned to resident.
INVESTIGATION FINDINGS:
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On 07/01/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director, Kasie Wimmer. The two met and reviewed the report below.

Regarding: Staff do not ensure residents hearing aides are charged.

In an interview with the Memory Care Director, Rose De La Garza, she stated that the Medication Technicians (MedTechs) were responsible for taking hearing aids during bed time medication passes so they could be charged and locked in the medication room overnight and then returned in the morning by care partners. De La Garza further explained that if the resident did not require bedtime medications, their assigned care partner would take the hearing aids and give them to the MedTech to charge in the medication room where they would be safe.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
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 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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This LPA reviewed care notes for the resident (R1) from 02/02/25 - 03/31/25 and observed the following entries:

02/02/25, S2 logged, "Resident hearing aid put into charge"
02/03/25, S2 logged, "Resident hearing aid put into charger"
02/06/25, S2 logged, "Resident hearing aid put into charger"
02/09/25, S2 logged, "Resident hearing aid put into charger"
02/10/25, S2 logged, "Resident hearing aid put into charger"
02/17/25, S2 logged, "Resident surrendered the hearing aid to MT"
02/20/25, S2 logged, "Resident hear aid and gave to MT"
03/21/25, S3 logged, “Resident lost hearing aid in the right side of his ear"
03/22/25, S4 logged, "Resident did not have their hearing aid when MT went to collect them before bed"
03/31/25, S2 logged that they “took R1's "hearing aids and gave them to the MedTech to charge"

According the responsible party for R1, their hearing aids were supposed to be charged every night. There are 58 days from 02/02/25 – 03/31/25. During that time period, care notes mentioned taking the hearing aids to charge a total of 8 times. There was no explanation as to why the hearing aids were not taken and charged on the other 50 days. There also was no documentation stating when, or if, hearing aids were returned to R1 in the morning. Two of the logs above mention that R1 lost or did not have their hearing aids on 03/21/25 and 03/31/25.

In separate interviews with the Directors of Maintenance and Memory Care, both stated that hearing aids have been found in the laundry on more than one occasion. The Director of Maintenance also stated that the hearing aids are usually brought to him after they have been washed and before they have been transferred into the large capacity dryers in the Assisted Living Building. The Memory Care Director stated that the first place they look for missing hearing aids, is the laundry room.

The Director of Memory Care also stated in their interview that the system they have in place now, where Medication Technicians or Care Partners take the hearing aids to recharge them at night and return them in the morning, must have come about after this complaint was filed and they realized they needed to have a specific procedure in place.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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LPA reviewed the Individual Service Plan for R1 dated 9/27/24. This report stated, "Resident hearing needs will be known by staff, Speak slowly and clearly, get close to resident Remind resident to wear hearing aids." Under Frequency, it stated "Needed" and that these reminders were to be given by care partners. The report went on to state, "Check and see if hearing aids are in and working, Assist resident in applying hearing aids in the morning. Take out at night. Assistance provided by: Staff/At community Frequency: PRN /As Needed." It did not state where the hearing aids were to be put, if they were to be recharged, and when they were supposed to be taken or returned.

LPA reviewed the resident's (R1's) service plan with an activation date of 2/26/26 and a last modified date of 4/16/25, the date this complaint was filed with Community Care Licensing. On page 3 of the Service Plan detail it stated," Hearing impairment- Resident's hearing needs will be known by staff. Speak slowly and clearly, get close to resident." The word care partner was next to this line to identify the person responsible for providing care. The service plan did not address the need for R1’s hearing aids to be charged or checked to ensure they were working properly. The second care plan provided less instruction than the first and did not allocate responsibility to anyone regarding these essential and expensive pieces of medical equipment.

LPA requested the contact information for the responsible parties of 3 residents in memory care who utilize hearing aids. Two out of the three interviewed stated that their family members’ hearing aids were not charged regularly. Two of the three stated that they would visit, and their family member and they would not have their hearing aids in. Both families stated that their resident’s hearing aids had been lost on multiple occasions. If the hearing aids were lost, misplaced, or found in the laundry, then they were not being charged.



Based on the documents reviewed and the interviews conducted, the standard for the preponderance of evidence has been met and the Department found "Staff do not ensure residents hearing aides are charged,"
SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management visit will also be conducted to address protecting the residents property (hearing aids) from being sent to the laundry.

Regarding: Staff are not following incontinent care plan for resident.

LPA reviewed R1's service plan with an activation date of 2/26/26 and a last modified date of 4/16/25. R1's LIC 602 stated that R1 had both bowel and bladder impairments. Under Continence Care: "Continence Care
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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- 60 min/day Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom."

LPA reviewed the Individual Service Plan for R1 dated 9/27/24.
With regard to Continence Care the report stated the following:
"Resident will be offered full assistance with toileting. Staff will offer approximately 60 minutes of full assistance while the resident uses the bathroom. Provided by Caregiver at the community. Frequency: Daily: Shift III - MC CP 2 NOC
Shift I MC CP 7 AM
Shift II MC CP 6 PM"

In an interview with Hospice provider (H1), they reported that when R1 was visited in the morning by their staff for care, their adult briefs were "saturated." LPA requested notes from contracted care provider visits.



The notes included the following logs:
On 02/06/25, the log stated," Patient soaked form the waist down upon arrival."
On 02/17/25, "provided bladder incontinent care."
On 03/10/25,"Diapers and pants were saturated with urine."
On 04/09/25, “Patient naked upon arrival, patient, bedsheet, underpants, and diapers wet with urine.”

In an interview with staff, S8, they stated that the care plan was not always followed because they would run out for briefs for R1. Sometimes we would borrow them from other residents or from the storage closet, if there happened to be extra in there and if they had the right size. S8 stated "We did our best to keep R1 dry but R1 was one of the residents who would wake up in the middle of the night, sit up and walk to the bathroom even though we had changed R1. R1 would rip off their briefs because R1 had to urinate then they would run out of briefs." This LPA asked how R1 was running out of briefs and S8 stated that sometimes R1's briefs were taken for other residents who may or may not have been on hospice and didn't have enough.

S8 stated that if another resident was on hospice we were told that it was OK for us to use other residents briefs that were also on hospice. S8 said that was why certain hospice supplies were running out for the specific residents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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S8 went on to state that "Even if R1 had 5-10 at any point. They were being used up at night because R1 would rip them off in R1's room and walk naked to the bathroom. Then when we would go and check on R1, I remember R1 would be sitting there and saying that they had to use the bathroom. “

Based on the review of documents and the interview conducted, the standard for the preponderance of evidence was met and the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management Visit will also be conducted to address the shortage of incontinence supplies and the need to conduct reappraisal so that care plans are updated to address the needs of the residents in care.

Regarding: Staff are not ensuring that resident laundry is being cleaned and returned to resident.

Based on interviews with S5 and S7, clothing often goes missing in memory care. Residents wander into one another rooms and take things that may look familiar or that they simply want. S7 stated that Laundry is done 7 days a week - beds and linens are changed every day. No washers and dryers are used in memory care so everything is moved to the laundry room in assisted living. Residents' clothing are all washed in individual mesh bags so they stay together.

S7 stated that 2 - 3 staff take the laundry to the laundry room where they have 8 washer and dryers. They work on the laundry until 5pm and then there is just 1 worker who finishes up, Everything gets returned the same day. S7's staff doesn't usually check pockets because memory care residents don't usually have valuables with them. If someone notices something bulky or jingling, they will remove it and return it or bring it directly to him.

S7 also stated that they have found hearing aids in the laundry. They find them when switching clothes from the washer to the dryer. S7 stated that he takes the batteries out and puts the hearing aids in the room across from the laundry room (it is very hot) to dry out, and they "Usually work after that." LPA asked if he could think of a time when they did not work and S7 replied, "No."



On 06/17/26, LPA Viarella visited rooms in the memory care community. LPA observed that only 1 in 3 of the rooms she visited 132, 135, and 142, only 135 had a mesh bag for their laundry. LPA took photos for documentation purposes. One did not have a mesh bag or liner and one had a plastic bag. LPA asked S5
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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what was done with the clothes or bedding that were found and staff were not sure who they belonged to? S5 stated that they would bring all of these items out to the dining room and staff would go through them and return them to residents. S5 said, "Some of them even had the names on the inside!"

Based on the observations made and the interviews conducted, the standard for the preponderance of evidence has been met and the Department found the allegation, "Staff are not ensuring that resident laundry is being cleaned and returned to resident. to be SUBSTANTIATED." This deficiency has been cited on the LIC 9099D page. LPA to conduct a Case Management regarding their theft and loss procedures.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Wimmer.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 10
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
04/16/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250416092323

FACILITY NAME:CARLTON SENIOR LIVING SACRAMENTOFACILITY NUMBER:
342701213
ADMINISTRATOR:WIMMER, KASIEFACILITY TYPE:
740
ADDRESS:1075 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:185CENSUS: 128DATE:
07/01/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kasie Wimmer Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not answer resident's alarm timely.
INVESTIGATION FINDINGS:
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On 07/01/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director, Kasie Wimmer.

Regarding: Staff do not answer resident's alarm timely.

LPA reviewed care notes from February 2 – March 31, 2025. LPA could find no documentation regarding bed alarms or alerts. LPA was told there were no alert call logs to review in the memory care community. LPA interviewed the responsible parties for 3 residents in memory care and 2 of the 3 stated that they have never heard alarms/alerts go off at all while they were visiting and did not have any experience with not having bed alerts not responded to.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
VISIT DATE: 07/01/2026
NARRATIVE
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Based on the review of documents and the interviews conducted, the standard for the preponderance of evidence was not met and the Department found the above allegation to be UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the allegation was untrue or did not happen, it means that there was not a preponderance of evidence to substantiate the allegation.

According to the California Code of Regulations, Title 22 not other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Wimmer.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2026
Section Cited
CCR
87464(f)(4)
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Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living...
The above requirement was not met as evidenced by:
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ED stated that they will send a message out in their monthly email explaining and promoting their hearing aid practices and procedures for the residents here at Carlton Senior Living. A copy of this email will be sent to CCL at their regional email by OCB 07/02/26.
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Based on a document review of care notes and care plans along with interviews with H1, F1, and F3, hearing aids were not being charged and returned to residents on a daily basis as needed. This posed an immediate threat to the health, safety, and personal rights of residents in care.
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Type A
07/02/2026
Section Cited
CCR
87625(b)(3)
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Managed Incontinence
(b) In addition to… (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
The above requirement was not met as evidenced by:
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ED stated they will conduct an addtional in-service on reporting and escalated reported. ED will also reach out to hospice agences they partner with to ensure they have enough incontinent supplies.
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Based on a review of records and interviews with F1, H1, S8, and F3, incontinence care was not being done enough and residents were not kept clean and dry. This posed an immediate threat to the health, safety and personal rights of 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: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 27-AS-20250416092323
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: CARLTON SENIOR LIVING SACRAMENTO
FACILITY NUMBER: 342701213
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2026
Section Cited
CCR
87218(a)
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Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.

The above requirement was not met as evidenced by:
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ED stated that they will conduct an audit of mesh laundry bags. There will also be an in-service for all laundry staff to check ALL pockets each time laundry is collected, and all resient laundry will be labeled going forward. ED will also communicate with families that there needs to be an inventory of items.
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Based on interviews with S8, F1, F2, F3, and H1 as well as with the Directors of Maintenance and Memory Care, the clothing and bedding were frequently lost in the laudry and not retuned to their proper owners. This posed a potential risk to the health, safety, and personal rights of residents in care.
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ED will commnicate new laundry procedure in monthly email. ED will send copy of in-service signature sheets and a sample of laundry audit by COB 7/31/26
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 10 of 10