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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604331
Report Date: 08/29/2024
Date Signed: 08/29/2024 08:37:23 PM

Document Has Been Signed on 08/29/2024 08:37 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MARANATHA DAY PROGRAMFACILITY NUMBER:
374604331
ADMINISTRATOR/
DIRECTOR:		GUIBERT, NICOLEFACILITY TYPE:
775
ADDRESS:1112 BROADWAY, #103TELEPHONE:
(619) 760-3322
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 45CENSUS: 41DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Nicole GuibertTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Dang Nguyen and Hannah Rodgers conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Nicole Guibert.

According to the facility’s license, the day program facility has a maximum capacity of forty-five (45) clients, of which five (5) may be non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of forty-one (41) clients enrolled, of whom one (1) was non-ambulatory and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present.

LPAs, accompanied by Licensee’s staff, also toured the interior and exterior of the facility and inspected all common areas and classrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows, sinks, and toilets were working. There were no sharp objects, toxic chemicals/poisons, or other hazards accessible to clients. Extra hygiene supplies and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate meals/snacks, visitation, meetings, and client activities.

LPAs observed, and manager interview confirmed, that the day program did not have carbon monoxide alarms installed, as required. Where tested, hot water temperature at two (2) of four (4) taps accessible to clients were too hot: Common Area Sink was 127 F and Break Room Sink was 122 F. However, the sinks in the public restrooms were complaint in temperature: Bathroom #1 Sink was 115 F and Bathroom #2 Sink was 113 F. The facility’s ambient internal temperature was complaint at 75 F. Appliances to preserve perishable food were also all compliant in temperature: Both refrigerators were 40 F, and Freezer was 0 F. Food that was present was safely stored. [CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 9
Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 04:47 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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not ensure that the facility had one or more carbon monoxide detectors [meeting the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12]. This posed an immediate health and safety risk to 41 of 41 clients (C1 through C41) in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agreed to purchase and install four (4) plug-in carbon monoxide detectors, distributing them to different rooms of the day program facility. Licensee agreed to E-mail a copy of the purchase receipt to LPA Nguyen, by the 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 04:47 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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82095.5(b)
Infection Control Requirements
(b) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 82022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not develop and maintain an Infection Control Plan for the facility as part of its Plan of Operation. This posed a potential health risk to 41 of 41 clients (C1 through C41) in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to write an Infection Control Plan for the day program (LPAs provided Licensee with CCLD Form 9283), and to then to train existing direct care staff on it, along with the correct process for donning and doffing Personal Protective Equipment (PPE). Licensee agreed to E-mail the completed Infection Control Plan and training sign-in sheet to LPA Nguyen, by the POC due date.
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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
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Based on measurement with instrument, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential health and safety risk to 41 of 41 clients (C1 through C41) in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to coordinate with building maintenance personnel to make adjustments to the existing hot water system to ensure that all taps deliver hot water between 105 F and 120 F. Licensee agreed to self-test the hot water temperature at all taps, and to contact and notify LPA Nguyen as soon as it is brought back into compliance, but no later than 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 04:47 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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain 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
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Based on records review and manager interview, Licensee did not maintain an individual written admission agreement for 5 of 5 clients (C1 through C5) reviewed during this inspection. This posed a potential personal rights risk to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to complete signed admissions agreements for C1 through C5, and to E-mail copies of such to LPA Nguyen by the POC due date. Licensee also agreed to complete admissions agreements for all other current clients in care, and for future clients. Licensee ageed to provide copies of executed admissions agreements to responsible persons, and to file the originals in the client binders.
Type B
Section Cited
CCR
82072(a)(8)(B)
82072 Personal Rights: “(a)(8)(B) A written order from the client's physician indicating the need for postural supports shall be maintained in the client's record.” This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview: 1 of 41 clients (C1) in care used a postrual support, and Licensee did not maintain in that client's record a written order from the client's physician indicating the need for it. This posed a potential personal rights risks to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to coordinate with C1's physician to obtain a written order indicating C1's need for their wheelchair seatbelt, and to add it to C1's care record. License then agreed to E-mail an Exception Request letter along with this physician's order to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov), and to CC LPA Nguyen (dang.nguyen@dss.ca.gov), by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 05:21 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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1507.15
1507.15: “Every community care facility that…offers an adult day program shall, for the purpose of addressing issues that arise when an adult resident or an adult day program participant is missing from the facility, develop and comply with an absentee notification plan for each resident or participant.” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: Licensee did not develop an absentee notification plan for 41 of 41 clients (C1 through C41) in care. This posed a potential safety risk to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to write a default Absentee Notification Plan for the ADP program, and then to add a copy of it to each client's care file beside the Needs and Services Plan. Where applicable, Licensee agreed to customize the plan to individual clients' needs. Licensee agreed to E-mail a copy of the default Absentee Notification Plan to LPA Nguyen, by the POC due date.
Type B
Section Cited
CCR
82068.3(a)
82068.3 Modification to Needs and Services Plan: “(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, for 4 of 5 client files (C1 through C4) reviewed during this inspection, Licensee did not ensure that the client's Needs and Services Plan was updated at least annually. This posed a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to complete a current LIC625 Appraisal/Needs and Services Plan for C1 through C4, and to have those plans reviewed and signed by the client's responsible person. Licensee agreed to E-mail the signed/completed LIC625s for C1 through C4 to LPA Nguyen, by the POC due date. Licensee agreed to complete/update LIC625's for all other current and future clients, and to update them at least once per year.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 05:32 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(a)
80069.2 Functional Capabilities Assessment: “(a) In order to determine whether the facility’s program meets a client’s services needs, the licensee of an ARF shall assess the client’s need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing [and] shall be used in developing the Needs and Service Plan…” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: For 5 of 5 client files (C1 thorugh C5) reviewed during this inspection, Licensee did not maintain a written functional capabilities assessment as part of the client's record of care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to complete and sign an LIC9172 Functional Capabilties Assessment for C1 through C5, and to E-mail copies of such to LPA Nguyen, by the POC due date. Licensee agreed to complete LIC9172's for all other current and future clients, and maintain them in the clients' files.
Type B
Section Cited
CCR
82072(b)
82072 Personal Rights: “(b) At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 82072(a)(1) through (10).” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: For 5 of 5 client files (C1 through C5) reviewed during this inspection, Licensee did not ensure that the client and their authorized representative were personally advised of and given the list of the rights specified in Sections 82072(a)(1) through (10). This posed a potential personal rights risks to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to have the clients and/or responsible persons for C1 through C5 sign CCLD form LIC613 Personal Rights, and to E-mail completed copies of such to LPA Nguyen, by the POC due date. Licensee also agreed to have all other current clients and future clients and their responsible persons sign the LIC613, and to maintain these forms as part the clients' files.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/29/2024 08:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/29/2024 at 05:50 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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
1565: “(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: Licensee did not provide training on the facility's emergency/disaster plan to each staff member upon hire and annually thereafter. This posed a potential safety risk to 41 of 41 clients (C1 through C41) in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agreed to conduct training for all current staff on its existing LIC610D Emergency/Disaster Plan and the staff's roles/responsibilities under it. Licensee agreed to submit the trianing sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to train all staff on its LIC610D both at time of hire, and annually thereafter.
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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331
VISIT DATE: 08/29/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Per the Licensee, this day program does not centrally store medications nor assist clients with medications. No firearms or ammunition are kept at the facility. There were no pools or bodies of water, open-faced heaters, or fireplaces on the premises. Fire detection system, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. Confidential records were stored in locked areas. Licensee presented proof of current business liability insurance.

LPAs reviewed records for multiple clients and multiple staff. LPAs interviewed multiple clients and staff. Records showed, and manager interview confirmed: Client #1 (C1) used a wheelchair seat belt, but Licensee did not maintain in C1’s record of care a written order from the client’s physician indicating the need for the postural support, as was required. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] Licensee did not have a written Absentee Notification Plan in place for any of the forty-one (41) enrolled clients, as required. Staff interviews showed that on the date of the inspection, Client #2 (C2) had a history of exit-seeking behavior.

For four (4) of five (5) client records reviewed [C1 through Client #4 (C4)], Licensee did not possess a written Needs and Services Plan or equivalent care plan for the client which had been updated within the last year, as required. For five (5) of five (5) client records reviewed [C1 through Client #5 (C5)], Licensee did not possess for these clients’ an Admissions Agreement, a Functional Capability Assessment, and proof that they or their responsible person were personally advised and given a list of the Clients’ Personal Rights, as was required.

Training records showed, and manager interview confirmed: Licensee had not trained its staff on the facility’s written Emergency Disaster Plan, either upon hire or annually thereafter, as required. Licensee also had not trained its staff on the facility’s Infection Control Plan, as required.


[CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331
VISIT DATE: 08/29/2024
NARRATIVE
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5
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8
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31
32
[CONTINUED FROM LIC 809-C, 1 of 2]

Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages) and three (3) deficiencies were cited per California Health and Safety Code. Plans of Correction were jointly developed with the Licensee. LPAs also issued three (3) Technical Violations (TVs) regarding staff First Aid Training, the program’s Register of Clients, and tight-fitting covers for trash cans.

An exit interview was conducted with Guibert, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided for today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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