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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 08/29/2023
Date Signed: 08/29/2023 06:26:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/24/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230324164609
FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 76DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are not meeting residents' care needs.

Facility does not have sufficient staff to meet the residents' needs in a timely manner

Facility does not have signs posted regarding oxygen use.

Facility staff are mismanaging residents' medications

Staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, conducted a medication count, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 08/29/2023
NARRATIVE
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Multiple relevant parties reported to the Department that facility staff do not provide assistance with incontinence care and/or bathing. Interview with resident (R3) indicated that they do not receive assistance with incontinence care and they went 5 to 6 weeks without a shower when they were requesting to have a shower. R3 stated they were refused both due to being required to use a shower chair. Interview with ED indicated that the facility required R3 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident. ED stated that R3 personally made the order for the shower chair and shower chair was not provided by the facility. ED stated that it took 30 days to obtain the first shower chair, in which resident refused to use due to being uncomfortable, and another 30 days to obtain a second shower chair that the resident was able to use. ED stated that R3 was originally admitted with the use of a hoyer lift, but R3 refused to use hoyer lift after admission due to being uncomfortable for resident. Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R3 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R3 indicated that R3 “requires two-person physical assistance with transfers.”

LPA reviewed R3's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R3 was in need of assistance with toileting and bathing. LPA reviewed R3's Preplacement Appraisal Information (LIC 603) and observed R3 is "unable to transfer unassisted" regarding toileting and needs services for bathing. LPA reviewed R3's Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 indicating that R3 "requires stand-by assistance for toileting," and 4/13/2023 indicating that R3 "requires hands-on assistance with incontinence; gathering incontinence supplies, hygiene, and/or changing linen." Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week. LPA reviewed the facility’s shift notes from April 2023 to August 2023 and Staff Assignments by Month by Unit for R3 from May 2023 to August 2023. LPA observed only the morning of 6/1/2023 documented as having R3 receiving incontinence care for the month of June 2023. LPA also observed only 1 bed bath documented for 6/1/2023 for the month of June 2023. All other entries for June 2023 were blank and not documented as care given. Bed baths and showers for R3 were documented inconsistently for the months of April 2023 and May 2023, with some weeks not having any bed baths or showers documented.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 08/29/2023
NARRATIVE
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ED was unable to provide any additional documentation regarding R3's incontinence care or bathing, including possible refusals. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation.

Multiple relevant parties reported to the Department that the facility does not have sufficient staff to meet the residents' care needs in a timely manner. Interview with staff member (S1) indicated that staffing could be better at the facility and that the facility needs more staffing. Interview with staff member (S2) indicated that PM shift in the Memory Care Unit (MCU) needs more staffing and that they noticed a lot of "call-offs" in the MCU during PM shift. Interview with staff member (S3) indicated that staffing at the facility could be improved and working at the facility can be "hectic." Interview with staff member (S8) indicated that some staff are just at the facility not working and it is hard for management to delegate those individuals. Interview with staff member (S9) indicated that some staff do what they want and are not pulling their weight, causing others to have to compensate. S9 stated that they do not see improvement with staffing. Interview with R3 indicated that they have used their call button pendant and will have to wait for staff’s response anywhere between 10 to 20 minutes, and has waited 40 minutes not receiving staff assistance and needing to contact the front desk for staff to respond.

Interview with ED indicated that standard response time to residents' call buttons is between 5 to 10 minutes, with no more than 15 minutes passing before responding to a resident's call button. ED stated that fall sensors should be responded to by staff immediately.

LPA reviewed History of SMARTcare (call button response time records) for 12/4/2022 through 12/6/2022, 12/21/2022 through 12/22/2022, and 12/26/2022 through 1/10/2023. At multiple times through the dates listed above, LPA observed call buttons "announced 9 times" with no time indicated when response was given. At multiple times through the dates listed above, LPA observed call buttons have response times exceeding 15 minutes and reaching as long as 42 minutes. LPA observed call button logs for R3 to have multiple response times exceeding 15 minutes and reaching as long as 38 minutes. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 5/12/2023, no additional citations will be issued regarding allegation.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 08/29/2023
NARRATIVE
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During visit conducted on 4/3/2023, LPA observed that resident (R1) did not have a “No Smoking-Oxygen in Use” sign posted outside of their apartment. Interview with Business Office Director on 5/1/2023 indicated that R1 was on oxygen for about one and a half (1 ½) months and would have been on oxygen during the visit conducted on 4/3/2023. Interview with ED conducted on 5/2/2023 indicated that R1 had been on oxygen since 2019 and would have been on oxygen during the visit conducted on 4/3/2023. LPA observed that oxygen sign was posted outside of R1’s apartment during follow-up visit. LPA observed a doctor's order for R1 dated 5/3/2023 stating that it is approved to administer oxygen as a PRN for R1.

Multiple relevant parties reported to the Department varying accounts of medication mismanagement by facility staff. LPA reviewed an internal document indicating that, on 1/1/2023 during a medication audit, it was found that a medication that was supposed to be given to a resident was not in the medication bin. Through more investigation, it was determined that the medication was reviewed and approved by Memory Care Director (MCD), Belinda Prunty, and listed to be “injected” even though the facility does not have injectable medication that they can administer. It was documented that MCD did not check to see if medication was at the facility and records indicated that medication had been marked as “given” by other med-techs.

During a visit conducted on 5/17/2023, LPAs Michael Hood and Angela Hood conducted a medication count for residents R1 and R2, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPAs observed three (3) medications for R1 that were off count in relation to what was documented. All three medications that were off count were over the amount documented. Facility was able to account for 1 day (4/29/2023) in which R1 was out of the facility, but no other refusals were documented that could account for the amount over what was documented.

LPA reviewed caregiver records for staff members S12, S13, and S14. LPA observed that S12 started working at facility on 11/11/2021. LPA observed only six (6) hours of online training completed within the first four (4) weeks of S12’s employment. LPA observed that S13 started working at facility on 2/15/2023. LPA observed only four (4) hours of online training completed prior to start date and five (5) hours of online training completed within the first four (4) weeks of S13’s employment.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 08/29/2023
NARRATIVE
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LPA observed that S14 started working at facility on 6/17/2018. LPA observed only thirteen and a quarter (13.25) hours of online training completed between the dates 1/6/2023 and 6/21/2023 on file for S14. LPA inquired if there was any other training documented for S12, S13, and S14. ED could not provide additional training documents for S12, S13, and S14. LPA reviewed a “shadowing checklist” to be completed for staff when they first start employment. However, shadowing checklist does not document the hours of training completed for each staff member.

Based on interviews conducted, a medication count, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for the date of 8/29/2023 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/30/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will conduct an in-service with all Med-Techs on medication administration. Facility will also conduct a medcation audit to address current errors. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date of 8/30/2023.
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Based on medication counts and records reviewed, the facility did not ensure that resident R1 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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Request Denied
Type B
09/13/2023
Section Cited
CCR
87618(b)(3)(B)
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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
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ED ensured that all apartments with residents using oxygen have "No Smoking-Oxygen in Use" signs on doors. ED will complete a statement of understanding regarding regulation 87618 and submit to department by POC due date of 9/13/2023.
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Based on observations, the facility did not ensure that "No Smoking-Oxygen in Use" sign was posted on every apartment door with a resident using oxygen, which poses a potential 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/13/2023
Section Cited
HSC
1569.625(b)(1&2)
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§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
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ED will follow-up with management group regarding required training indicated in Health and Safety Code and ensure staff complete required training. Facility will also complete a statement of understanding regarding Health and Safety Code §1569.625 and submit to LPA by POC due date of 9/13/2023.
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Based on records reviewed, facility did not ensure that staff were acquiring all required trainings per Health and Safety Code, which poses a potential health, safety, and personal rights risk to residents in care.
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A civil penalty of $250 is assessed for a repeated violation.
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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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/24/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230324164609

FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 76DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are not providing residents with food of good quality.

Facility is not allowing visitation

Facility is unclean and in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 59-AS-20230324164609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 08/29/2023
NARRATIVE
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During visits conducted on 7/21/2023 and 8/29/2023, LPA observed kitchen for the ability to prepare and store food. LPA observed a 2-day perishable and 7-day nonperishable food supply on the premises. LPA observed kitchen to be clean, in good repair, and free of debris and pests. LPA did not observe any open containers or expired food items in the food storage. LPA observed resident dietary restrictions posted in kitchen area. LPA observed menus posted from the facility and observed that the facility is providing three meals a day with snacks throughout the day. All interviews conducted with staff and residents indicated that residents have options for meals.

Interviews conducted with staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, and S11 indicated that the facility allows visitors for the residents. Interviews with residents R2, R3, R4, and R5 indicated that they have no concerns regarding obtaining visitation. LPA observed visitor log to demonstrate that the facility is currently allowing visitors.

Multiple relevant parties reported to the Department that the facility was either unclean or in disrepair on separate occasions. Interviews conducted with staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, and S11 as well as residents R4, R5, R6, and R7 indicated that they have no issues with housekeeping or have never witnessed anywhere in the facility to be unclean or in disrepair. During visits conducted at the facility, LPA did not observe the facility or any apartments to be unclean or in disrepair.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9