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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846276
Report Date: 06/11/2025
Date Signed: 06/11/2025 03:46:09 PM

Document Has Been Signed on 06/11/2025 03:46 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:ANGELES FAMILY CHILD CAREFACILITY NUMBER:
364846276
ADMINISTRATOR/
DIRECTOR:		ANGELES, JUDITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 728-2050
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 9DATE:
06/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Judith AngelesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Eric Ramos 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 06:00 PM.
Off-limit areas include: Garage, 2nd Floor, Living/Dining Room, Kitchen

· 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 not stored and inaccessible to children. During facility tour, LPA observed Clorox wipes and a febreze spray bottle underneath the sink in the on-limit restroom that is used by daycare children.
· Toxins are not 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 not barricaded. During facility tour, LPA observed that the stairs by the front door are not barricaded.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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 06/11/2025 03:46 PM - It Cannot Be Edited


Created By: Eric Ramos On 06/11/2025 at 02:32 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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observation, the licensee did not comply with the section cited above in that the stairs by the front door are not barricaded which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee agrees to barricade the stairs by the front door and submit proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or by the POC due date.
Type B
Section Cited
CCR
102417(g)(4)
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.

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 Clorox wipes and a febreze spray bottle underneath the sink in the on-limit restroom that is used by daycare children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee immediately removed the Clorox wipes and febreze bottle to an inaccessible area of the home. Licensee agrees to submit a written statement on their understanding of the above regulation and how they will maintain compliance and submit proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before 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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 03:46 PM - It Cannot Be Edited


Created By: Eric Ramos On 06/11/2025 at 02:32 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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in that the last fire drill conducted was on 07/09/2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee agrees to conduct a fire drill and disaster drill and submit proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before the POC due date.
Type B
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 in that the 15 minute sleep checks for C1 were not conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Per Licensee's own admission, she did not conduct 15 minute sleep checks for C1. Licensee agrees to conduct 15 minute sleep checks for C1 and provide proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before 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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 03:46 PM - It Cannot Be Edited


Created By: Eric Ramos On 06/11/2025 at 02:32 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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

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 S1 and S2 were missing the Employee Rights Form (LIC9052) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee agrees to have S1 and S2 complete the Employee Rights Form (LIC9052) and provide proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before POC due date.
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 in that C4's LIC700 form was not completed and signed by authorized representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee agrees to have authorized representative complete and sign C4's LIC700 form and submit proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before 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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 03:46 PM - It Cannot Be Edited


Created By: Eric Ramos On 06/11/2025 at 02:32 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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 a completed LIC282 form on file with authorized representative's signature which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2025
Plan of Correction
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Licensee agrees to have authorized representative complete and sign the LIC282 form and submit proof of Plan of Correction (POC) to Community Care Licensing (CCLD) on or before POC due date.
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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276
VISIT DATE: 06/11/2025
NARRATIVE
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· 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 not on file – Last drill conducted on 07/09/2024.
· Mandated Reporter Training expires on 10/27/2026.
· Pediatric CPR and First Aid Card expires on 01/24/2026.
· Health & Safety Certificate - completed on 01/28/2022.
· 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. During record review, LPA observed that C4's LIC700 was not completed and signed by authorized representative. Additionally, C1 did not have a completed LIC282 on file with authorized representative's signature.
· Employee’s records are not complete. During record review, LPA observed that S1 and S2 were missing the Employee Rights Form (LIC9052).
· The licensee provided proof of control of property.
· Because the licensee rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the licensee confirms was provided to the property owner/landlord. The licensee obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Resident and/or staff records reviewed on 06/11/2025 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.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276
VISIT DATE: 06/11/2025
NARRATIVE
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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.

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.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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: ANGELES FAMILY CHILD CARE
FACILITY NUMBER: 364846276
VISIT DATE: 06/11/2025
NARRATIVE
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***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 951-782-4200.

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 the licensee Judith Angeles.

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


***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/process.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
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