<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 07/10/2026
Date Signed: 07/10/2026 04:15:54 PM

Document Has Been Signed on 07/10/2026 04:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOVING LEGACY SENIOR CARE IIFACILITY NUMBER:
342701578
ADMINISTRATOR/
DIRECTOR:		BANUVE, VENIANAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(279) 229-7719
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
07/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Barbara Williams, staff on dutyTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 10, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct the annual inspection. LPA met with staff on duty, Barbara Hall-Williams (S1) and stated the purpose of the visit. The administrator, Veniana Banuve (AD) was not available to be present during this visit. According to S1, today is AD’s day off. Per review of the LIC500 dated 05-11-2026, AD was scheduled Monday through Friday from 7am to 7pm. Present during this visit were five residents in care with two staff on duty, Barbara Hall-Williams (S1) and Donovan Williams (S2).

This annual visit is being conducted with a complaint investigation of Complaint # 27-AS-20260414141418.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas.

  • Inspection of the kitchen refrigerator – LPA observed a box of injectable insulin belonging to resident. The box is not lockable and is accessible to other residents in care.
  • Cleaning solutions were accessible – Lysol All Purpose Cleaner found inside the bathroom sink in the master bathroom; under the kitchen sink, though it was locked using a bicycle lock, it was still accessible as LPA was able to open it and LPA was able to reach inside the opening; and a purple liquid in a spray bottle placed on the ground outside by the exit gate. Photos were taken.
  • Sliding door in the master bedroom was difficult to slide open (advisory was already provided from previous visit).
  • In the master bathroom, the shower is missing one shower door.
  • LPA is unable to determine the correct temperature of the kitchen refrigerator and freezer during this visit. Advisory was provided from previous visit for facility to obtain a thermometer for each.

{1 of 2}
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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 14
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578
VISIT DATE: 07/10/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Record Review: Review of 5 of 6 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Review of 3 staff files included but not limited to background clearance, first aid/CPR certification, and training.
  • Staff on duty (S1 and S2) did not have their health screen in their files.
  • Staff did not have training records related to restricted health conditions for the residents with restricted health conditions.
  • 5 of 5 residents did not have PRN Authorization letter signed by their physician.
  • Resident(s) receiving home health services did not have a written agreement on file.
  • Resident(s) with restricted health condition did not have Restricted Health Care Plan on file.

Interviews: 3 residents were interviewed.
  • 2 of 3 stated facility do not provide alternative food or second serving when requested.

General Observation: Throughout this visit, LPA did not observed staff offering or conducting activities with residents.

Documents Requested: LPA requested a copy of updated Liability Insurance, updated LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and/or Health and Safety Code, deficiencies were cited. Facility is hereby assessed immediate civil penalties in the amount of $2000 total due to repeat violations.

Plan of correction and appeal procedures were discussed during exit interview with AD. A copy of the report and appeal rights were provided.

{2 of 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, Lysol All Purpose Cleaner found inside the bathroom sink in the master bathroom; under the kitchen sink, though it was locked using a bicycle lock, it was still accessible as LPA was able to open it and LPA was able to reach inside the opening; and a purple liquid in a spray bottle placed on the ground outside by the exit gate, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2026
Plan of Correction
1
2
3
4
Corrected on site: Staff on duty removed the cleaning solutions and changed the lock for the kitchen sink cabinet.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, staff on duty (S1 and S2) did not have their current health screen. S1's health screen was dated in 2022 and she was started working at this facility on May 2026. S2 did not have his health screen on file for review. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2026
Plan of Correction
1
2
3
4
Licensee will develop a plan to ensuring all staff working at this facility will have their health screen completed as required. Submit plan by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, Staff did not have training records related to restricted health conditions for the residents with restricted health conditions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Licensee will obtain training from a licensed profession related to the specific restricted health conditions of the residents in care for all staff. Submit proof of training by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed a box of injectable insulin belonging to resident inside the kitchen refrigerator. The box is not lockable and is accessible to other residents in care. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2026
Plan of Correction
1
2
3
4
Corrected on site: staff on duty obtained a lockable box for this medication.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews, 5 of 5 residents did not have PRN Authorization letter signed by their physician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Licensee shall obtain PRN Authorization Letter for each of their residents. Submit proof by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, sliding exit door in the master bedroom was difficult to slide open. Per interview with resident, they have difficulty sliding the door (Note that advisory was already provided from previous visit for the other exit sliding door).
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Licensee will submit a plan ensuring all exit doors are easy to operate in case of emergency. Submit plan by POC due date.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA did not observe staff offering or conducting activities with residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Licensee will develop a monthly activity calendar base on residents' needs and post it in the area of the facility where residents are able to review. Submit a sample activity calendar for the month of July 2026 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 07/10/2026 04:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/10/2026 at 03:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with 3 residents, 2 of 3 stated facility do not provide alternative food or second serving when requested which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Licensee will develop a weekly menu, along with alternative menu, base on residents' needs. Submit July menu by POC due date.
Type B
Section Cited
CCR
87609(b)(4)(A)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). (A) The written agreement shall reflect the services, frequency and duration of care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, resident(s) receiving home health services did not have a written agreement on file.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Obtain a written agreement from home health agency and submit it by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 9 of 14