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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619579
Report Date: 07/29/2025
Date Signed: 07/29/2025 02:13:44 PM

Document Has Been Signed on 07/29/2025 02:13 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JOHNSON, DANITAFACILITY NUMBER:
343619579
ADMINISTRATOR/
DIRECTOR:		JOHNSON, DANITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 706-7332
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
07/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Danita JohnsonTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 07/29/2025, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Danita Johnson (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. Also present in the FCCH was L1’s spouse. LPA observed 1 infant, 2 preschool aged children and 6 school aged children being supervised by L1 and her spouse. LPA accessed Guardian to determine that all required adults were background cleared and associated to the license. L1 stated that there are no new residents in the home since licensure and confirmed that there are no Registered Sex Offenders living in the facility. LPA completed the RSO profile on 07/29/2025.
LPA toured the areas of the FCCH that are accessible to children in care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include entire 2nd floor, laundry room, and garage. L1 acknowledged that children may never enter these OFF-limits areas. L1 reports her hours of operation to be Monday through Friday from 6:30 am until 6:00 pm. L1 stated that she does not provide overnight or weekend care.
LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA reviewed the children’s files but not all requested files were provided by L1. LPA reviewed the adult’s files and some required immunizations. LPA reviewed the Facility’s Roster and the Fire Drill log. The last fire drill logged was April 2024. LPA reminded L1 that drills are to be conducted at least once every 6 months. A functioning smoke detector and carbon monoxide detector were tested downstairs. LPA observed cleaners stored in a kitchen cabinet that was behind doors with child safety locks; however, the child locks are warn and not effective. LPA reminded L1 to replace the locks. LPA observed knives on the kitchen counter, and L1 moved the knives to an inaccessible locations. Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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Document Has Been Signed on 07/29/2025 02:13 PM - It Cannot Be Edited


Created By: Katy Velazquez On 07/29/2025 at 12:27 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: JOHNSON, DANITA
FACILITY NUMBER: 343619579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above when an open staircase was observed with children less than 5 years old present in the FCCH, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
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LPA will conduct an insection to clear the citation.
Type A
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when LPA requested sleep logs for an infant enrolled in day care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
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Licensee and Aide(s) will review the Safe Sleep packet that LPA provided. Licensee will email LPA a written statement confirming that she and Aide(s) have read the packet in entirety by 5:00 PM on 07/30/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 02:13 PM - It Cannot Be Edited


Created By: Katy Velazquez On 07/29/2025 at 12:27 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: JOHNSON, DANITA
FACILITY NUMBER: 343619579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above when the Family Childcare Home was observed to have piles, spider webs, trash, and covered counters in the home, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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LPA will conduct an inspection to clear this citation.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when LPA observed the fire drill log to record the last drill in April 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Licensee will conduct a fire drill and email LPA the log by 5:00 PM on 08/05/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 02:13 PM - It Cannot Be Edited


Created By: Katy Velazquez On 07/29/2025 at 12:27 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: JOHNSON, DANITA
FACILITY NUMBER: 343619579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when Licensee and Aide's files did not contain proof of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee and all Aide(s) will conduct Mandated Reporter training, and Licensee will email LPA certificates as proof of completion by 5:00 PM on 08/08/2025.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when an Adult Aide's file did not contain proof of MMR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Proof of MMR immunization for Earl Johnson will be emailed to LPA by 5:00PM on 08/29/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/29/2025 02:13 PM - It Cannot Be Edited


Created By: Katy Velazquez On 07/29/2025 at 12:27 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: JOHNSON, DANITA
FACILITY NUMBER: 343619579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when children's files were not complete for all children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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LPA will conduct an inspection to clear this citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOHNSON, DANITA
FACILITY NUMBER: 343619579
VISIT DATE: 07/29/2025
NARRATIVE
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The fireplace in the living room was observed to have a glass barricade; however, L1 stated that the fireplace is not used during operational hours. LPA observed a staircase that was not barricaded while children under age 5 years old were present in the FCCH. LPA observed a 2A10BC fire extinguisher in the kitchen that appeared to have a reading in the green zone. LPA did not observe any bodies of water on the premises. LPA walked the perimeter of the backyard and ensured the stability of the surrounding fence. LPA observed play structures in the back yard that appeared to be in working condition but were not properly cushioned. LPA reminded L1 to obtain cushion under the play structures (slides and swings) before day care children utilize the equipment. L1 stated there are no firearms in the FCCH and that she owns 3 dogs.

LPA discussed Mandated Reporter Training with L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. L1 has expired Mandated Reporter training. Current Pediatric CPR and First Aid training was also verified by LPA and will expire on 07/2027.

LPA discussed the Safe Sleep Regulations with L1 and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed L1 of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended that s/he register all infant devices with the CPSC to be notified of any recalls on purchased equipment.

Incidental Medical Services (IMS) policy was discussed with L1. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOHNSON, DANITA
FACILITY NUMBER: 343619579
VISIT DATE: 07/29/2025
NARRATIVE
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information through this communication platform. To receive important licensed related information, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. L1 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, PRIOR to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours per day per day. L1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. L1 understands that if any structural changes are made to the FCCH; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years.


If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
Title 22 deficiencies were cited on subsequent 809-D page(s). LPA informed Licensee Johnson that this report, dated 07/29/2025, document(s) 2 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOHNSON, DANITA
FACILITY NUMBER: 343619579
VISIT DATE: 07/29/2025
NARRATIVE
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Also, LPA Velazquez informed L1 to provide a copy of this licensing report dated 07/29/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted, and the report was reviewed with Licensee Johnson. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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