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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604552
Report Date: 01/28/2026
Date Signed: 01/28/2026 12:54:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20260107115647
FACILITY NAME:ACORN OAKS MANOR IIFACILITY NUMBER:
374604552
ADMINISTRATOR:LIMPIN, ALEXANDERFACILITY TYPE:
740
ADDRESS:6217 ACORN STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:14CENSUS: 12DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex LimpinTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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-Licensee did not meet resident(s)’ personal care needs.
-Licensee did not maintain toilet paper in bathroom.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex Limpin.

The Complainant alleged that Licensee did not meet Resident(s)’ personal care needs and that Licensee did not maintain toilet paper in bathroom. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of all residents in care, outside sources, and multiple facility managers and caregivers. The Department also reviewed pertinent care records.


[CONTINUED ON LIC 9099-C, 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 01/28/2026
NARRATIVE
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[CONTINUED FROM LIC 9099]

Regarding the first allegation: The Complainant said Resident #1 (R1) relied on staff help for changing their clothes, but that Licensee’s staff do not regularly provide this help, as required. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] The Complainant said R1 relied on staff help with grooming (to include shaving), but Licensee’s staff did not regularly provide this help, as required. The Complainant said Resident #2 (R2) did not have the manual dexterity to peel an orange, and that Licensee’s staff would hand R2 whole oranges without peeling them, meaning R2 could not eat these fruits.

According to the care assessments/plans which Licensee authored on R1 and R2, both residents were supposed to receive assistance with bathing (twice per week), dressing (twice per day), and grooming (twice per day). Grooming assistance included toenail and fingernail care. During his 01/14/2026 visit, LPA observed: R1 and R2 were in reasonably clean clothing. Neither person had foul body odor. The same was true for all other residents of the facility. However, R1 had unkempt facial hair around an inch-long. R1 had long/overgrown toenails. R2 had long/overgrown fingernails and toenails. Resident #3 (R3) also had overgrown fingernails.

Interviews of staff and outside sources aligned to show: Those facility residents who could not bathe independently were typically assisted by staff with bathing twice per week, according to a facility shower schedule (which LPA obtained a copy of). Resident interviews widely corroborated that twice-per-week bathing help was provided, in practice. Almost half the time, R1 refused to be showered, despite repeated attempts/encouragement by caregivers, which was R1’s right to do. Multiple staff reported that R1 was not shaven because they had refused to be shaved. However, R1 expressed to LPA on 01/14/2026 that they preferred to be shaven, and that they would accept shaving help if it was offered to them, which LPA relayed to staff that same day. (On LPA’s return visit on 01/28/2026, LPA observed R1’s beard and moustache had been neatly trimmed/groomed.) Staff interviews showed mixed answers and a lack of general clarity among the caregivers as to who was responsible for residents’ fingernail and toenail care, and at what frequency such care should be rendered. R1 told LPA that staff indeed typically peeled and cut their oranges for them. Staff interviews widely corroborated this.

[CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 01/28/2026
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Regarding the second allegation: The Complaint said there have been a few occasions between August 2025 and early January 2026 when they observed no toilet paper available in a hallway bathroom shared by the facility’s residents. During his 01/14/2026 facility visit, LPA also observed that one (1) of the facility’s two (2) shared bathrooms had no toilet paper. LPA instructed staff to add more toilet paper that day. On LPA’s return visit on 01/28/2026, both bathrooms had toilet paper inside them.

Based on records and interviews, a preponderance of evidence exists to show that at least during the complaint timeframe, Licensee did not meet residents’ personal care needs and that Licensee did not maintain toilet paper in bathroom. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2026
Section Cited
CCR
87464(f)(4)
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87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living...” This requirement is not met, as evidenced by:
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By the date of deficiency issuance (01/28/2026), Licensee had completed trimming of R1’s facial hair and toenails; License had also completed trimming of R2’s and R3’s fingernails. Licensee agreed to make arrangements for trimming of R2’s toenails, and to retrain staff that per the residents’ care plans, residents are to receive oral hygiene care and dressing assistance at least twice per day. Licensee agreed to send LPA a photographs of R2’s trimmed toenails (after completion) and a copy of the staff training sign-in sheet, by the POC due date.
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Based on records and interviews, Licensee did not provide 3 of 12 residents (R1, R2, and R3) assistance with activities of daily living and care as needed by the resident. This posed a potential health and personal rights risk to persons in care.
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Type B
02/28/2026
Section Cited
CCR
87307(a)(3)(D)
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87307 Personal Accommodations and Services: “(a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available…the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper.” This requirement was not met, as evidenced by:
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During LPA’s 01/14/2026, Licensee restocked the indicated bathroom with toilet paper. During LPA’s 02/28/2026 visit, both bathrooms remained stocked with toilet paper. Licensee agreed to train its caregivers to double-check that there is toilet paper in both the dispenser and on the counter in each shared bathroom, at the start of each work shift. Licensee agreed to E-mail the staff training sign-in sheet to LPA, by the POC due date.
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Based on interview and LPA observation, Licensee did not ensure that 1 of 2 shared bathrooms was stocked with toilet paper. This posed a potential health and personal rights risk to 10 of 12 residents (R1 though Resident #10) in care.
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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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20260107115647

FACILITY NAME:ACORN OAKS MANOR IIFACILITY NUMBER:
374604552
ADMINISTRATOR:LIMPIN, ALEXANDERFACILITY TYPE:
740
ADDRESS:6217 ACORN STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:14CENSUS: 12DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex Limpin.TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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3
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-Licensee did not timely respond to resident(s)’ calls for assistance.
-Licensee did not keep facility free of incontinence odors.
-Licensee did not maintain facility cleanliness.
-Licensee did not maintain comfortable facility temperature.
-Licensee did not keep facility free of insects.
-Licensee did not keep passageway free of obstruction.
-Licensee did not provide clean bedding.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex Limpin.

The Complainant alleged that Licensee did not timely respond to resident(s)’ calls for assistance, that Licensee did not keep facility free of incontinence odors, that Licensee did not maintain facility cleanliness, that Licensee did not maintain comfortable facility temperature, that Licensee did not keep facility free of insects, that Licensee did not keep passageway free of obstruction, and that Licensee did not provide clean bedding. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of all residents in care, outside sources, and multiple facility managers and staff. The Department also reviewed pertinent care records and photographic evidence. [CONTINUED ON LIC 9099-C, 1 of 3]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 01/28/2026
NARRATIVE
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[CONTINUED FROM LIC 9099-A] LPA met privately with all (12) residents in care, finding two (2) did not have the mental ability to answer questions. LPA also interviewed two (2) managers and four (4) direct care staff.

The Complainant said most of the time when either Resident #1 (R1) or Resident #2 (R2) pushed their call button, Licensee’s caregivers did not respond to it at all. [See LIC811 Confidential Names list for a description of select person identifiers used in this report.] During his 01/14/2026 visit, LPA tested the call buttons for R1 and R2, finding both devices were working and transmitting a signal to the med tech station, as expected. Of the ten (10) residents who could answer questions about this topic, six (6) said they were ambulatory and thus generally did not use their call buttons. Of the remaining four (4) residents, only one (1) complained of slow response time. Interviews of managers and caregivers aligned to show that caregivers aimed to respond to call signals as soon as they heard them (unless they were already in middle of providing care to another resident) and that caregivers generally worked as a team to timely meet such calls for service.

The Complainant said during their 01/05/2026 visit, strong urine and fecal odors pervaded the facility (rather than being specific to any room or resident). During his own 01/14/2026 and 01/28/2026 visits, LPA did not smell odors of incontinence in facility common areas or resident bedrooms; the facility smelled fine. Of the ten (10) residents who could answer questions about this topic, nine (9) said the facility smelled fine to them, and one (1) did not have an opinion on the topic. Interviews of the managers and staff did not reveal evidence of the facility being malodorous.

The Complainant said on multiple days between August 2025 and early January 2026, the floor of R1 and R2’s shared bedroom had trash/debris on the floor. They also said facility staff did not clean R1’s bedside table of food debris, and that on 01/05/2026, there was a fecal stain on R1 and R2’s window curtain. During his own 01/14/2026 and 01/28/2026 visits, LPA did not see trash/debris on the bedroom floor of R1/R2, or any other resident’s bedroom or common area. R1's bedside table was also clean. The facility’s walls were clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) said Licensee’s staff kept the facility in a state of general cleanliness. Manager interview showed that on an earlier date, there was indeed a stain on the window curtain of R1/R2, but this was chocolate Ensure (not feces), and the curtain was soon changed out for a clean one. LPA reviewed a photograph of the curtain in question, taken on the date in question; the splatter patterning was more consistent with the Ensure explanation (i.e., it did not look like feces). [CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 01/28/2026
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

Complainant said on 01/05/2026, the facility temperature fell to around 53 F, because staff left both of the facility’s two (2) front doors ajar at night. During his own 01/14/2026 visit, LPA observed the facility’s temperature was in the low 70s (well-within in the required range described in regulation). LPA also observed that Licensee kept extra portable heaters on the premises and available to deploy to resident rooms, upon demand. Of the ten (10) residents who could answer questions about this topic: Nine (9) said the facility temperature was consistently kept comfortable. Resident interviews widely aligned to show that staff typically kept the facility’s two (2) front doors closed at nighttime. Multiple residents confirmed remembering heavier rainfall during early January 2026, but said the facility was kept warm with heaters. Only one (1) resident said the facility was often too cold (to include the date of LPA’s 01/14/2026 visit). However, this last resident also stated that when they felt cold, staff provided them with blankets. (LPA witnessed this resident using three blankets during his visit). When LPA returned on 01/28/2026, the facility was again at a warm and comfortable temperature. Interviews of managers and caregivers did not produce evidence of the facility being too cold, even during the earlier week that the Complainant had referenced.

The Complainant said R2 was bitten by insects while inside the facility. During his 01/14/2026 and 01/28/2026 visits, LPA did not observe any live or dead insects inside the facility. Of the ten (10) residents who could answer questions about this topic: Eight (8) denied the facility having any insect problem. One (1) resident did not have a clear opinion on the topic. One (1) resident said they had been bitten by mosquitoes on their head and cheek, but they declined to let LPA look closely at their head, and LPA did not see any bites on their face. Interviews of a facility manager plus an outside source showed that at one point during the complaint period, this last resident received a visitor who brought a dog that laid on the resident’s bed. Upon receiving an allegation of an insect bite to said resident (prior to CCLD receiving the complaint), facility staff changed that resident's bed sheets and contacted the visitor to provide them notice and instruction. The available evidence cannot reliably establish that this visitor’s dog had fleas; even if their dog did, there is no evidence of Licensee culpability here.


[CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20260107115647
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 01/28/2026
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3]

The Complainant said there was a period when R1’s hospital bed stuck out to the point that it obstructed their bedroom door from being closed. Interviews of managers, caregivers, and an outside source, along with video, showed: During late 2025, Licensee undertook a project to widen the doorframes of its residents’ bedrooms to make them more wheelchair-friendly. As part of this project, the shared bedroom door belonging to R1 and R2 was also widened. During the complaint period, R1’s/R2’s bedroom door could not be swung closed because it would contact the end of R1’s bed. After a few weeks, staff fixed the issue by rearranging/reorienting R1 and R2’s beds within the room to prevent blocking the door’s swing. Based on the specific circumstances and dimensions involved, CCLD concluded that the passageway into and out of R1’s bedroom was not blocked to the degree that people were materially slowed when coming in and out of the room. (However, the inability to close the bedroom door represented a privacy violation, which will be cited in a separate Case Management report.)

Complainant said facility staff let R1 lay atop bedsheets that were dirty with food residue, rather than put clean sheets on R1’s bed. During his 01/14/2026 and 01/28/2026 visits, LPA briefly observed the beds and bedding of the twelve (12) residents in care, finding all were reasonably clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) affirmed that staff consistently provided them with clean sheets and bedding. Residents widely reported that facility caregivers typically changed their sheets and pillowcases twice per week on their scheduled shower days, plus on request. Interviews of the managers and caregivers corroborated this.

Based on records and interviews, a preponderance of evidence does not exist to show that that Licensee did not timely respond to resident(s)’ calls for assistance, that Licensee did not keep facility free of incontinence odors, that Licensee did not maintain facility cleanliness, that Licensee did not maintain comfortable facility temperature, that Licensee did not keep facility free of insects, that Licensee did not keep passageway free of obstruction, and that Licensee did not provide clean bedding. These seven (7) allegations are therefore Unsubstantiated, and no deficiencies were cited for them.

An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8