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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601232
Report Date: 10/10/2025
Date Signed: 10/10/2025 04:49:10 PM

Document Has Been Signed on 10/10/2025 04:49 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:JOY'S HOMECAREFACILITY NUMBER:
374601232
ADMINISTRATOR/
DIRECTOR:		LIGAYA SANDERSFACILITY TYPE:
735
ADDRESS:1406 I AVENUETELEPHONE:
(619) 474-0198
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 6CENSUS: 6DATE:
10/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Manager Marianne Alfaro and Volunteer Lisa VanceTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Manager Marianne Alfaro and Volunteer Lisa Vance. LPA also spoke with Licensee/Administrator Ligaya Sanders over the phone to inform them of LPA's visit. The facility's license shows a maximum capacity of six (6) ambulatory clients only. During today’s inspection there were six (6) total residents in care, but two (2) were physically present at the facility. Note, LPA did step out for lunch from 12-1pm.
 
LPA and Manager Alfaro toured the interior and exterior of the facility and inspected each room. LPA noted evidence of rodents throughout the facility via droppings. Pathways were free of obstruction and slip hazards, however LPA noted rips throughout the carpet and laminate flooring which could pose as trip hazards. Per interviews with staff, the floor damages were caused by rodents. Client bedrooms contained all required furnishings except for chairs/additional seating. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were not compliant: Kitchen sink was 102F and common bathroom sink measured at 92.3F; compliant hot water range is 105-120F. Extra linens and hygiene supplies were present.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, however, LPA noted open containers of food in the fridge as well as pests. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: JOY'S HOMECARE
FACILITY NUMBER: 374601232
VISIT DATE: 10/10/2025
NARRATIVE
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[Continued from LIC 809]

While most chemicals or poisons were kept locked and inaccessible to clients, LPA observed two jugs of laundry detergent in a shared client room. LPA explained to the occupying client why chemicals needed to be safely stored and inaccessible to other clients. The client agreed to have their laundry jugs stored with the other facility chemicals and staff moved them to secured areas. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per both Manager Marianne Alfaro and Volunteer Lisa Vance, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Facility fire extinguisher was serviced within the last 12 months, dated for March 2025. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed two (2) staff and one (1) client, and interviews did reveal some licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA did not contain all required documents. Confidential records were stored in locked areas.

Eleven (11) deficiencies were cited during the inspection. An exit interview was conducted with Manager Alfaro to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 03:16 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above in ensuring that the facility was kept sanitary from odors, droppings, and damages caused by rodents and other pests, which poses a potential health and safety risk to 6 out of 6 persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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2
3
4
Licensee will submit proof of pest/rodent treatment and sanitation and/or remediation of flooring and other items damaged by pests/rodents to LPA by POC due date.
Type B
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 LPA observation and interview, the licensee did not comply with the section cited above in ensuring toxic chemicals were kept secured and inaccessible to clients, which poses a potential health and safety risk to 6 out of 6 persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Staff immediately secured laundry jugs in locked chemical storage area. Licensee will submit proof of retraining/review of toxic/chemical items storage to LPA 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 03:16 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation], the licensee did not comply with the section cited above in ensuring water temperature was in compliant temperature range, which poses a potential health, safety or personal rights risk to 6 out of 6 persons in care.
POC Due Date: 10/20/2025
Plan of Correction
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2
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4
Licensee will adjust water heater accordingly to reach compliant water temperature and submit log of temperature readings conducted for a period of one week to LPA by POC due date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on LPA observation, the licensee did not comply with the section cited above in ensuring client rooms included a chair, which poses a potential personal rights risk to 6 out of 6 persons in care.
POC Due Date: 10/20/2025
Plan of Correction
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Licensee will submit proof of chairs being placed in client rooms to LPA 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 03:16 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA file review and interviews, the licensee did not comply with the section cited above in ensuring quarterly staff drills were conducted, which poses a potential health, safety and personal rights risk to 6 out of 6 persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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2
3
4
Licensee will submit proof of emergency drill conducted with staff to LPA by POC due date.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring there was a qualified and certified facility Administrator, which poses a potential health, safety and personal rights risk to 6 out of 6 persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Licensee will submit proof of renewal of Administrator certification or hire a new and qualified administrator and submit required documentation to LPA 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 03:16 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA file review, the licensee did not comply with the section cited above in ensuring two (2) staff members had health screenings and TB tests, which poses a potential health and safety risk to 6 out of 6 persons in care.
POC Due Date: 10/31/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of health screenings + TB tests conducted for staff S1 and S2 and submit to LPA by POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review,, the licensee did not comply with the section cited above in ensuring all residents had a signed admissions agreement within their file, which poses a potential personal rights risk to 1 out of 6 persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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2
3
4
Licensee will submit a copy of a complete and signed admissions agreement for client 1 (C1) to LPA 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 03:51 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file review, the licensee did not comply with the section cited above in ensuring all residents had an annually updated physician's report and/or needs and services plan, which poses a potential health, safety and personal rights risk to 4 out of 6 persons in care.
POC Due Date: 10/31/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of updated appraisal and/or physician's report (LIC 602) or appointment scheduled to do so for C1, C2, C3, and C4 to LPA by POC due date.
Type B
Section Cited
CCR
80072(a)(3)

80072(a): each client shall have personal rights which include, but are not limited to, the following: (3) To be free from […] actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above in ensuring clients had access to the kitchen area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
1
2
3
4
Licensee will discontinue locking the kitchen and ensure that chemicals and knives/sharps in the kitchen are secured and kept inaccessible to clients in care, and submit proof to LPA 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 10/10/2025 04:49 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/10/2025 at 04:00 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: JOY'S HOMECARE
FACILITY NUMBER: 374601232

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(6)

80066(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: (6) Documentation of the educational background, training and/or experience specified in licensing regulations for the type of facility in which the employee works.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review and interviews, the licensee did not comply with the section cited above in having documentation of staff training, which poses a potential health, safety and personal rights risk to 6 out of 6persons in care.
POC Due Date: 11/10/2025
Plan of Correction
1
2
3
4
Licensee will ensure all staff receive proper and full training as required for their role and submit proof to LPA by 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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