<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408320
Report Date: 06/15/2024
Date Signed: 06/15/2024 02:41:58 PM

Document Has Been Signed on 06/15/2024 02:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:LMB CARE HOMEFACILITY NUMBER:
366408320
ADMINISTRATOR/
DIRECTOR:		BRANDON DELGADOFACILITY TYPE:
735
ADDRESS:1125 WEST "J" STREETTELEPHONE:
(909) 460-9372
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 3DATE:
06/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Administrator Isabelita DeramosTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/15/2024 at 08:55 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA Brown was greeted by Staff #3 (S3) and gained access at the home. LPA Brown explained the purpose of the visit to S3. Administrator Isabelita Deramos was contacted and arrived during the visit.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, Personal and Incidental (P & I) audit, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed one client during the visit. Administrator Deramos reported that two (2) clients’ were out in the community. There are no obstructions to indoor but LPA Brown observed obstructions to outdoor/backyard area. Deficiency will be issued. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown and inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility does not have night lights maintained in common hallways towards clients common bathroom. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinet but LPA Brown observed that medications were not locked, making it accessible to clients. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320
VISIT DATE: 06/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Brown observed two (2) knives and three (3) scissors not locked in the kitchen and accessible to clients in care. Deficiency will be issued. In addition, LPA Brown observed two (2) window screens in disrepair and one (1) screen door and both not free of dirt. Technical Violation Issued.

Yards/Outside: One shaded patio, two (2) side gate with self-latching handle on the left and right side of the house that leads into the backyard, attached two (2) car garage observed. The outdoor was not free of obstruction as evidenced of of old clothes, bags, bins, gates, broken screen doors and other items piled out in the backyard. LPA Brown observed the shed outside the facility/backyad with chemicals not locked making it accessible to clients in care. Deficiency will be issued.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly. LPA Brown observed facility menu posted in a common area.


Care & Supervision: Facility does not have sufficient care staff for coverage 24 hours a day, 7 days a week. LPA Brown observed no staff coverage from 7:00 AM to 11:00 PM on Sat and Sunday in reference to the facility's Personnel Report (LIC500) as staff indicated to work those days does not have criminal background clearance. Deficiency will be issued.

Record Review: LPA Brown reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA Brown observed that all Client files reviewed were complete. LPA Brown also reviewed three (3) staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #3 (S3) does not have First Aid/CPR certification, working at the facility since 05/26/2024 without criminal background clearance, no trainings provided before employment and no health screening completed and no tuberculosis test result maintained in S3 facility file. Deficiencies will be issued.

Also, LPA Brown observed Tenant #1 living at the facility without criminal background clearance since 05/26/2024. Deficiency will be issued and civil penalty will be assessed.

During today's visit, the facility will be cited for civil penalty of $500.00 for S3 working at the facility without criminal background clearance and $500.00 for T1 for living at the facility without criminal background clearance will continue to be assessed of $100.00/day until corrected. *** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking the two (2) knives and three (3) scissors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80087(g) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
Licensee immediately locked the two (2) knives and three (3) scissors during the visit. POC cleared.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not locking the shed outside of the facility/at the backyard with chemicals inside making it accessible to their clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80087(g)(1) and submit proof of all staff training log to LPA Brown on POC due date.
Licensee immediately locked the shed outside the facility/at the backyad during the visit. POC cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to work at the facility on 05/26/2024 prior to obtaining S3's criminal backround clearance and allowing Tenant 1 (T1) to live at the facility on 05/26/2024 prior to obtaining T1 criminal backround clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to remove S3 and T1 at the facility and submit proof to LPA Brown of updated new staff schedule on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to work at the facility without a Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of S3 Health Screening Report or Health Screening Report Medical Appointment whichever is applicable to LPA Brown on 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to work at the facility without Tuberculosit Test document maintained in S3 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of S3 Tubersulosis Test document to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not providing on the job training to Staff #3 for safe and effective job performance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
LIcensee stated to provide schedule of Staff #3 On-the Job Training for Safe and Effective job performance and submit proof to LLPA Brown on 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85065(b)
Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having the required number of staff as necessary to ensure provision of care and supervision to meet their client needs as evidenced of the staff scheduled working on weekends from 7:00 AM to 11:00 PM as staff indicated to work does not have fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
LIcensee stated to update their work schedule/Personnel Report (LIC500) for staff coverage and add additional staff if needed and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having Staff #3 (S3) complete the required training for First Aid from persons qualified by agencies including but nt limited to the American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to submit Signed Statement of Understanding on CCR 80075(f) to LPA Brown on 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not loicking the medications cabinet making it accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80075(k)(1) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date,
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 06/15/2024 02:41 PM - It Cannot Be Edited


Created By: Melody Brown On 06/15/2024 at 12:34 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not keeping the outdoor area free of obstruction as evidenced of old clothes, bags, bins, gates, broken screen doors and other items piled out in the backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
1
2
3
4
Licensee stated to remove the obstructions at the backyard and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not maintaining night lights in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchse night lights and install in hallways and passages to nonprivate bathrooms and submit proof to LPA Brown on 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320
VISIT DATE: 06/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Moreover, LPA Brown audited two (2) clients’ medications and no issues were observed. LPA Brown audited three (3) client's P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102, LIC421BG and Appeal Rights were discussed, and copies were provided to Administrator Isabelita Deramos.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024
LIC809 (FAS) - (06/04)
Page: 11 of 11