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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364816883
Report Date: 09/02/2026
Date Signed: 09/02/2026 03:38:26 PM

Document Has Been Signed on 09/02/2026 03:38 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SLEEGE FAMILY CHILD CAREFACILITY NUMBER:
364816883
ADMINISTRATOR/
DIRECTOR:		SALLY SLEEGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 644-9678
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 4DATE:
09/02/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Sally SleegeTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On date and time listed above, Licensing Program Analyst (LPA) Laura Mejorado arrived at the facility to conduct an annual inspection and was granted entry by Licensee, Sally Sleege. Also present was Licensees spouse/assistant and four daycare children. LPA toured the facility, reviewed records, and observed and/or discussed the following:

Days and hours of operation are Monday- Friday, 7:00am – 6:00pm

OFF-LIMIT AREAS INCLUDE: All bedrooms (1-3), garage, shed in the backyard, and left and right side of the backyard beyond the gate.

The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited this visit.

Licensee is present and operating within the licensed capacity with appropriate supervision and ratio.

A working telephone and appropriate fire extinguisher are present. Smoke and carbon monoxide detectors are present and were tested by the Licensee during this inspection.

All hazardous items are inaccessible to children. Storage of poisons/toxins are not locked. During inspection LPA observed cleaning compounds which were out of reach and/or behind a latch, however, were not locked. Items had a warning label to contact poison control if consumed. LPA informed Licensee items need to be maintained under lock. Licensee removed the items in the bathroom but need to keep the items in the laundry area under lock. A type B citation was issued.

Ana Noble
Laura Mejorado
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883
VISIT DATE: 09/02/2026
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Fireplace is properly screened.

No stairs; this is a single story home.

Facility is clean, orderly and has adequate heating and ventilation.

Facility has safe, age-appropriate toys for indoor and outdoor activities. Outdoor play area is fenced.

Verification of control of property on file: Property owner/landlord notification and consent on file.

The following postings are visible: License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148); Parent’s Rights Poster (PUB393); and facility sketch.

Pediatric CPR and First Aid Card expires on 8/2027 (Licensee) and 7/2028 (Assistant)

Mandated reporter: Child Care expires on 11/18/27 (Licensee) and not on file for Assistant. A type B citation was issued.

Fire clearance granted on 4/27/10.

Documentation of fire & earthquake drills completed on 7/14/26

Children/Infant records are not complete. Two type B citations were issued for missing records.

Employee records are not complete. Two type B citations were issued for missing records.

Guns or weapons are present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.

There are no bodies of water during this visit Licensee understands all bodies of water must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of water bodies.

Additionally, the following was reviewed with Licensee.

- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.

NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Laura Mejorado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883
VISIT DATE: 09/02/2026
NARRATIVE
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- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see http://www.chp.ca.gov

-Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov

-Duty Officer availability: Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766)

- Access to forms & Regulations online at http://www.ccld.ca.gov

-Licensee is responsible to know the regulations for anyone providing care.

-Failure to meet the posting requirements shall result in an immediate civil penalty.

-To receive important licensed -related information to licensed facilities, 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

- Licensee 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.

- Incidental Medical Services (IMS) policy was discussed. 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/.

- Licensee 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.

NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Laura Mejorado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883
VISIT DATE: 09/02/2026
NARRATIVE
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- LPA discussed the safe sleep regulations with licensee 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 licensee of the importance of checking for and removing any recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

- To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. 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.

See LIC809D for cited deficiencies.

During the exit interview, the Licensee Sally Sleege, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Sally Sleege.

NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Laura Mejorado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 03:38 PM - It Cannot Be Edited


Created By: Laura Mejorado On 09/02/2026 at 02:39 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that cleaning compounds were inaccessible but not locked, which poses/posed a potential health, safety or personal rights risk to persons in care. Items in the bathroom were removed, however, items in the laundry area need to be locked and/or removed.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to submit pictures of the cleaning compounds in the laundry area under lock or removed. Licensee agrees to submit correction to community care licensing by 10/2/26.
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the crib in use did not have a tight fitting sheet, sheet present was loose which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to submit proof of a tight fitting sheet in the crib. Licensee agrees to submit correction to community care licensing by 10/2/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Laura Mejorado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 03:38 PM - It Cannot Be Edited


Created By: Laura Mejorado On 09/02/2026 at 02:39 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

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 in that A1 did not have a mandated reporter certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to submit mandated reporter (child care provider AB1207) certificate for A1. Licensee agrees to submit correction to community care licensing by 10/2/26.
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 in that A1 did not have a copy of their measles on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to submit a copy of A1s measles. Licensee agrees to submit correction to community care licensing by 10/2/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Laura Mejorado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/02/2026 03:38 PM - It Cannot Be Edited


Created By: Laura Mejorado On 09/02/2026 at 02:39 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed daycare children in an off limit area (garage), which poses/posed a potential health, safety or personal rights risk to persons in care. Per Licensee the garage is not used for daycare services and children were out their temporarily while Licensee spoke to their spouse. LPA did not observe any immediate dangers.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to submit a written statement of their understanding of this regulation ensuring children are not in off limit areas. Licensee agrees to submit correction to community care licensing by 10/2/26.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 in that C1 did not have LIC9227 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee agrees to obtain a completed LIC9227 for C1. Licensee agrees to submit correction to community care licensing by 10/2/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Laura Mejorado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 03:38 PM - It Cannot Be Edited


Created By: Laura Mejorado On 09/02/2026 at 02:39 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SLEEGE FAMILY CHILD CARE
FACILITY NUMBER: 364816883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that 15 minute sleep checks were not documented for C1, which poses/posed a potential health, safety or personal rights risk to persons in care. A log was present however log only documented started and end time of nap.
POC Due Date: 09/11/2026
Plan of Correction
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Licensee agrees to submit a week worth of 15 minute sleep checks for C1. Licensee agrees to submit correction to community care licensing by 9/11/26.

LPA went over safe sleep regulations and provided a copy of PIN 20-24-CCP.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Laura Mejorado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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