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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600996
Report Date: 09/27/2026
Date Signed: 09/27/2026 10:40:31 PM

Document Has Been Signed on 09/27/2026 10:40 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VELASCO HOMES #5, THEFACILITY NUMBER:
374600996
ADMINISTRATOR/
DIRECTOR:		SANFORD, LAILANI JOYFACILITY TYPE:
740
ADDRESS:1564 MALTA AVENUETELEPHONE:
(619) 476-7011
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
09/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver, Demetria MangobaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Demetria Mangoba (S1). During the visit, Caregiver Teresa Legaspi (S2) arrived at the facility. S2 had a current criminal record clearance; however, S2 was not associated with the facility in Guardian. During the visit, Backup Administrator Elizabeth Velasco arrived at the facility to assist staff in meeting the residents’ needs.

According to the facility’s license, the facility has a maximum capacity of six (6) residents. Residents may be ambulatory or non-ambulatory; however, no residents may be bedridden. At the time of today’s inspection, the facility had six (6) residents in its census. Four (4) residents were physically present at the facility, and two (2) resident were temporarily out of the facility. Of the six (6) residents, two (2) were ambulatory. None of the residents were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither type of door was observed at the facility.

LPA, accompanied by facility staff, toured the interior and exterior of the facility and inspected the common areas and resident bedrooms. During the inspection, R1 sustained a fall while attempting to transfer from a recliner to a walker. LPA observed that S1 was unable to assist R1 from the floor. S1 telephoned facility management and other staff members to request assistance. S2 arrived at the facility approximately one hour later. S1 and S2 attempted to assist R1 from the floor but were initially unsuccessful. R1 remained on the floor for approximately two hours. (Page 1 of 3 continue at LIC809C)
Sabel Martinez
Marisela Garcia-Centeno
DATE: 09/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2026
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996
VISIT DATE: 09/27/2026
NARRATIVE
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(Continue from LIC809)


R1 subsequently regained sufficient strength to get from the floor to the bed with assistance from S1 and S2. LPA did not observe any apparent injury to R1 following the fall.

Following the incident, R1 remained in bed for approximately two hours. R1 was subsequently observed transferring from the bed to the desk and then to the living room. R1 remained seated on the couch listening to music for two hours and then R1 was observed sitting in their recliner in his room. LPA confirmed with R1 no feeling any pain or discomfort.

During the facility tour, the facility was observed to be clean, sanitary, and in good repair. Pathways were free of obstructions and apparent trip hazards. One resident bedroom had a strong odor of urine, and the resident’s bed did not have linens. Resident bedrooms contained the required furnishings. Doors, windows, and screens, toilets, and showers were operational. Extra linens and hygiene supplies were available.

The facility had sufficient space and equipment to accommodate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient indoor temperature was measured at 80°F. Hot water temperatures at taps accessible to residents were within the required range. Refrigerators and other appliances used to store perishable food were maintained at compliant temperatures. At least two (2) days of perishable food and at least seven (7) days of nonperishable food were available and safely stored. Cooking and dining equipment and utensils were available.
No toxic chemicals, poisons, open-faced heaters, or other hazardous items accessible to residents were observed. Medications were appropriately labeled and stored in locked areas. Carbon monoxide detectors, smoke detectors, night lights, emergency lighting, and the facility telephone were observed to be operational. The facility fire extinguisher had been serviced within the previous twelve (12) months. No fireplaces or pools/bodies of water were observed on the premises. According to the Licensee, no firearms or ammunition are maintained at the facility.
Required licensing postings were observed in visible areas of the facility. The Licensee provided proof of current business liability insurance and surety bond.

(Page 2 of 3 Continue at LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Marisela Garcia-Centeno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996
VISIT DATE: 09/27/2026
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(continue from LIC809C)


During review of resident records, no deficiencies were identified. Review of personnel records disclosed that current health screenings were not maintained for S1 or S2.

Deficiencies were cited pursuant to California Code of Regulations, Title 22, and are documented on the LIC 809-D pages. Civil penalty of $500, as applicable, is documented on the corresponding LIC 421BG. Plans of Correction were developed jointly with Administrator Lailani Velasco and Elizabeth Velasco.

An exit interview was conducted with Administrator Elizabeth Velasco. LPA provided the Administrator with a copy of this report, the LIC 809-Ds, LIC421BG, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights during today’s visit.



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NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Marisela Garcia-Centeno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2026 10:40 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 09/27/2026 at 02:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews and personnel record review, the licensee did not comply with the section cited above in 2 or 3 S1 was not sufficient in number and then S2 were still not sufficient in number to assist a Resident (R1) after a fall which resulted in R1 to remain on the floor for extended period of time (more than 2 hours) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2026
Plan of Correction
1
2
3
4
Licensee agreed to submit a staffing plan and staff schedule to ensure sufficient staff are present at the facility to meet the needs of the residents in care. In addition, licensee agreed to conduct additional training with staff on proper techniques to employ when assisting residents during transfers. Documentation of POC will be submitted to CCL by POC deadline.
Type A
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above. When the facility management is out of the facillty there should be qualified/competent staff to provide coverage. During the visit, S1 and S2 required assistance during a resident fall and staff were not readily available to provide the assistance required to meet residents needs. This poses an immediate health, safety or personal rights risk to 5 of 6 persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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2
3
4
Licensee agreed to submit staffing plan to include coverage when facility managment is out. In addition, licensee agreed to provide training to direct care staff to ensure residents needs are met during transfers. Documentation of POC should be submitted to CCL by POC deadline.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/27/2026 10:40 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 09/27/2026 at 02:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87415(a)(1)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and ecord review the licensee did not comply with the section cited above, licensee did not have adequate staff scheduled to work during the weekend shifts which poses an immediate health, safety or personal rights risk to 5 of 6 persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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Licensee agreed to submit a staff schedule to ensure enough staff is scheduled to provide coverage during all shift. Documentation of staff schedule will be submitted POC deadline.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviewand record review, the licensee did not comply with the section cited above in, S2 was not associated to the facility which poses an immediate health and safety risk to persons to 5 of 6 persons in care.
POC Due Date: 09/28/2026
Plan of Correction
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4
Licensee agreed to associate S2 as soon as possible. Proof of associated will be submitted within 24 hours.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/27/2026 10:40 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 09/27/2026 at 02:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviewlicensee did not comply with the section cited above, one resident room had strong incontinance odor, which posed a potential health and personal rights risk to 1 of 5 persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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2
3
4
Licensee agreed to provide training to staff to ensure the residents' rooms are kept clean, safe and sanitary. Documentation will be submitted to CCL by POC Date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2026 10:40 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 09/27/2026 at 02:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. Caregivers S1 and S2 were observed having physical limitations that may intere during transfer assist activities to meet residents needs. This posed a potential health, safety or personal rights risk to non-ambulatory persons in care.
POC Due Date: 10/27/2026
Plan of Correction
1
2
3
4
Licensee agreed to evaluate current staffing needs for the facility in order to ensure the residents' needs are being met. Documentation of staffing plan will be submitted to CCL by POC deadline.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2026 10:40 PM - It Cannot Be Edited


Created By: Marisela Garcia-Centeno On 09/27/2026 at 02:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(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) A health screening as specified in Section 87411, Personnel Requirements - General.

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 in, S1 and S2 did not have current health screening on record, which posed a potential health, safety or personal rights risk to 5 of 6 persons in care.
POC Due Date: 10/27/2026
Plan of Correction
1
2
3
4
Licensee agree to submit proof of health screening for all staff employed at the facility. Documentation will be submitted to CCL by POC deadline.
Type B
Section Cited
CCR
87411(d)(3)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above in, S1 and S2 were observed not using proper techniques during transfers, which posed a potential health, safety or personal rights risk to persons in care and staff.
POC Due Date: 10/27/2026
Plan of Correction
1
2
3
4
Licensee agreed to submit documentation of training completed by POC deadline.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Marisela Garcia-Centeno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2026


LIC809 (FAS) - (06/04)
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