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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845575
Report Date: 10/21/2025
Date Signed: 10/21/2025 12:35:40 PM

Document Has Been Signed on 10/21/2025 12:35 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:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
364845575
ADMINISTRATOR/
DIRECTOR:		JOHNSON, LATOYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 816-1280
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
10/21/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:La Toya JohnsonTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPAs) Eric Ramos and Elyse Jones arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday-Friday 06:00 AM to 05:30 PM
Off-limit areas include: 2nd Floor, Garage, Left Side Yard

· The facility is operating within the licensed capacity and appropriate ratios.
· Appropriate supervision was provided during this inspection.
· A working telephone is present, and the current number is on file.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· There is no fireplace present.
· All hazardous items are stored and inaccessible to children.
· Toxins are locked.
· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.
· Stairs are barricaded.
· Clean, safe and age-appropriate toys.
· Current roster on file.
· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights are posted.
· Documentation of fire and disaster drills on file – Last drill conducted on 10/18/2025.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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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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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575
VISIT DATE: 10/21/2025
NARRATIVE
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· Mandated Reporter Training expired 7/21/2025.
· Pediatric CPR and First Aid Card expires on 8/2027.
· Health & Safety Certificate completed.
· No bodies of water currently. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar products must be emptied immediately after use and stored in an upright position.
· Children’s records are not complete.
· Employee’s records are complete.
Resident and/or staff records reviewed on 10/21/2025 indicate all adults who require caregiver background checks have received all required clearances and/or exemptions.

The following items were discussed with the Licensee during inspection:

- 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: http://www.ada.gov/childqanda.htm.

- The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov.
- The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov.

- 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: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575
VISIT DATE: 10/21/2025
NARRATIVE
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- LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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 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.
- 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 communication platform. 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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

***To access on-line Licensing forms & Regulations for a Family Child Care Home please visit: www.ccld.ca.gov.
***The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

See LIC809-D for cited deficiencies.

A notice of site visit was given 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. Exit interview conducted, and report was reviewed with Licensee La Toya Johnson.

During the exit interview, Licensee La Toya Johnson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2025 12:35 PM - It Cannot Be Edited


Created By: Eric Ramos On 10/21/2025 at 11:51 AM
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child 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 meet the above regulation which his poses a safety risk to the children in care. During the facility file review of the LPA was unable to review a documented fire log. Licensee was able to show a picture from the Great Shake Out.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all fire drills must be logged at least once every six months. Licensee documented the date during the inspection.

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:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2025 12:35 PM - It Cannot Be Edited


Created By: Eric Ramos On 10/21/2025 at 11:51 AM
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025

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 meet the above regulation which his poses a safety risk to the children in care. During the file review of the staff’s file the LPA was unable a current Mandated Reporter certificate for S1.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all staff must have a current Mandated Reporter on file during inspection. Licensee understand Mandated Reporter must be taken every two years. Licensee agrees to have S1 take the training and agrees to submit a certificate of completion on or by POC due date. Training can be take at www. Mandatedreporterca .com
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the Licensee did not meet the above regulation which his poses a safety risk to the children in care. During the file review of the children’s file the LPA was unable to review an immunizations for C4.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all children must have current immunizations on file during an inspection. Licensee agrees to obtain immunizations for C4 and submit to the Department on or 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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 10/21/2025 12:35 PM - It Cannot Be Edited


Created By: Eric Ramos On 10/21/2025 at 11:51 AM
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the Licensee did not meet the above regulation which his poses a safety risk to the children in care. During the facility file review of the staff’s file review the LPA was unable to review a current roster.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all children must be added to the roster upon their start date. When a child disenrolls it must be documented. Licensee added children during the inspection.
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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2025 12:35 PM - It Cannot Be Edited


Created By: Eric Ramos On 10/21/2025 at 11:51 AM
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the Licensee did not meet the above regulation which his poses a personal rights risk to the children in care. During the file review of the children’s file the LPA was unable to review an LIC 995 Notification of Parents Rights for C1.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all children must have an LIC 995 on file. Licensee agrees to obtain an LIC 995 for C1 and place in their file. Licensee also agrees to obtain an LIC 995 for C1 and submit to the Department on or 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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2025 12:35 PM - It Cannot Be Edited


Created By: Eric Ramos On 10/21/2025 at 11:51 AM
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364845575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review the Licensee did not meet the above regulation which his poses a safety risk to the children in care. During the file review of the children’s file the LPA was unable to review an LIC 9227 Individual Infant Sleeping Plan for C1.
POC Due Date: 10/28/2025
Plan of Correction
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2
3
4
Licensee understands all children under the age of 12 months must have an LIC 9227 on file. Licensee agrees to obtain an LIC 9227 for C1 and submit a written statement of understanding of the regulation to the Department on or by POC due date.
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the Licensee did not meet the above regulation which his poses a safety risk to the children in care. During the file review of the children’s file the LPA was unable to review sleep logs for C1 and C3.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee understands all children under the age of 24 months must have a daily sleep on file. The sleep log times must be accurate and every minutes. If the child does not sleep at the facility then the log should note that. Licensee agrees to start sleep logs for all children under the age of 24 months and submit a written statement of understanding of the regulation to the Department on or by the 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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2025


LIC809 (FAS) - (06/04)
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