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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100030
Report Date: 09/17/2026
Date Signed: 09/17/2026 01:33:14 PM

Document Has Been Signed on 09/17/2026 01:33 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 N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ODEESH, TANYA FAMILY CHILD CAREFACILITY NUMBER:
376100030
ADMINISTRATOR/
DIRECTOR:		TANYA ODEESHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 729-6734
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 0DATE:
09/17/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Tanya OdeeshTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 9/17/26 at 9:15 am, Licensing Program Analyst (LPA) Gerald Poindexter identified himself and disclosed the nature of the visit before being granted entry. LPA conducted an unannounced annual inspection with the licensee, Tanya Odeesh. Present in the home were the licensee’s mother, adult brother, and husband/helper, Thaer Issa – all residents. The licensee utilized friends and relatives by phone for interpretation fromm Arabic and Chaldean, including Lobna Daood and Salwa Issac. Licensee stated that she has 15 day care children enrolled, Monday through Friday, from 7:30 am to 12 am. There were no daycare present at the home during the inspection. The licensee was provided with the Inspection Checklist (LIC 126). The single level home was toured and inspected to ensure an environment safe for the care and supervision of children.

The licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include: living room, dining room, kitchen, bedroom #1, bathroom #1 and backyard. Off limits areas include garage, bedroom #2, Bedroom #3 and bathroom #2 – all inaccessible through use of door knob covers. Kitchen drawers and cabinets are latched. The licensee has a fully-fenced backyard available for outdoor activities. LPA inspected both sections of the backyard and observed no hazards. The licensee stated that she understands that visual supervision is always required during outdoor activities. There are no other bodies of water at the home. The licensee has sufficient toys and equipment available.

There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector that meet requirements and are operational. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children due to safety latches and high placement. Adequate heating and ventilation are provided. There is a working telephone and email address. There is no fireplace. Licensee advised there are no firearms or ammunition stored on the premises. CONTINUED ON PAGE 2

Joelle Redding
Gerald Poindexter
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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 N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030
VISIT DATE: 09/17/2026
NARRATIVE
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LPA observed all required postings were posted. Children’s records were reviewed and found to be incomplete. Staff records were reviewed and found to be complete. Pediatric CPR and First Aid expire 7/2028 and 7/2027 for the licensee and her helper, respectively. Licensee’s and helper’s Mandated Reporter AB1207 training certification are waived due to language. They speak Caldean and Arabic. Staff /resident immunization requirements were met. All required health/safety and facility-related documents were visibly posted. LPA reminded the applicant that pediatric CPR/First Aid must be renewed every two years.

Emergency drills were conducted and documented with the most recent drill on 6/2/26. Licensee did not maintain a current roster of the children. LPA verified that all adults living or working in the home have been fingerprint cleared and associated. LPA reminded Licensee that all unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203. Duty officer number is (619) 767-2248.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms; corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA conducted child care quality management staff interview with the licensee. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. CONTINUED ON PAGE 3
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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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 N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030
VISIT DATE: 09/17/2026
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

See LIC809D for deficiencies cited.

Exit interview conducted and report was reviewed with the licensee Tanya Odeesh. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A Notice of Site Visit was given and must remain posted for 30 days. Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 01:33 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 09/17/2026 at 11:51 AM
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 STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review and interview, the licensee did not have immunization records on file for the only infant in care, child C1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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The licensee stated that she will have parents of child C1 provide the missing immunization records and will submit copies to LPA Poindexter by the POC Due Date. Email to Gerald.Poindexter@dss.ca.gov
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not have child files nor licensing paperwork for 5 of 15 children enrolled, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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2
3
4
The licensee stated that she will have parents of children C1 through C5 provide completed and signed paperwork, and will submit proof to LPA by the POC due date. Email to Gerald.Poindexter@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 01:33 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 09/17/2026 at 11:51 AM
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 STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not maintain an update child care facility roster, as several children enrolled were not included, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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Licensee states she will submit a complete roster of enrolled children to the Department by the POC Due Date. Email to Gerald.Poindexter@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 01:33 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 09/17/2026 at 11:51 AM
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 STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not have completed and signed LIC995A forms for 8 of 15 children enrolled] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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The licensee stated that she will have parents provide completed and signed LIC995A Notification of Parents Rights forms, and will submit proof to LPA by the POC due date. Email to Gerald.Poindexter@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 01:33 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 09/17/2026 at 11:51 AM
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 STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not have the Individual Infant Sleep plan on file for the only infant in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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2
3
4
The licensee stated that she will have parents provide completed and signed LIC9227 form, and will submit proof to LPA by the POC due date. Email to Gerald.Poindexter@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not have a Safe Sleep Log on file for the only infant enrolled, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
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2
3
4
LPA reviewed the requirement of the Safe Sleep Log with the licensee, who stated she will begin maintaining the log immediately. Licensee will submit the sleep documentation to LPA by POC due date and keep updated in the future. Email to Gerald.Poindexter@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 01:33 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 09/17/2026 at 11:51 AM
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 STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ODEESH, TANYA FAMILY CHILD CARE
FACILITY NUMBER: 376100030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(g)
Staffing Ratio and Capacity
(g) For the purpose of meeting the criteria in Sections 1597.44 and 1597.465 of the Health and Safety Code, for a school age child who is under age six, the licensee shall maintain documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary
school.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not have proof of enrollment documents for 2 of 2 child under age 6 years which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
The licensee stated that she will have the childrens parents provide proof of enrollment for the current school year and will submit the documents to LPA by the POC due date. Email to Gerald.Poindexter@dss.ca.gov
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.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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