<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300852
Report Date: 09/23/2026
Date Signed: 09/23/2026 01:25:46 PM

Document Has Been Signed on 09/23/2026 01:25 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:REYES FAMILY CHILD CAREFACILITY NUMBER:
376300852
ADMINISTRATOR/
DIRECTOR:		REYES,JOSEFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 277-4530
CITY:OCEANSIDESTATE: CAZIP CODE:
92058
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 7DATE:
09/23/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Josefina Reyes, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tricia Danielson conducted an unannounced annual inspection for a large family childcare at the above home on 09/23/2026 at 9:35 AM. LPA met with staff Juana Morales who guided LPA on a tour of the home. During this visit, the facility had a total of 11 children enrolled and 7 children were present with Morales and an assistant when LPA arrived. Licensee Josefina Reyes arrived shortly thereafter.
The facility operates Monday through Friday from 5:00 AM to 9:00 PM each day. Certain areas are off-limits, including the primary bedroom and bathroom, bedroom #2, kitchen, and garage. The facility is licensed as a large Family Child Care Home (FCCH) with a maximum capacity of 14 children and is operating within the licensed capacity of the license. A fire clearance for 14 children was granted on 1/17/2024 by Oceanside Fire Department.
During the inspection, LPA observed Licensee Reyes to be responsive and aware of where the children were at all times. A working cell phone is available, and the current phone number on file is correct. A fully charged fire extinguisher (3A:40BC) was observed, along with a functioning smoke detector and carbon monoxide detector, both of which were tested by Licensee Reyes. There is no fireplace at the home. All hazardous items, including toxins, are stored securely and are inaccessible to children. There are no weapons present in the home. Licensee Reyes understands that all firearms, weapons, and ammunition must be locked separately and made inaccessible as per Title 22 Regulations. There are no stairs in the home.
The facility provides clean, safe, and age-appropriate toys for children. A current roster is on file, and required postings, including the Facility Sketch, License, and Notification of Parent’s Rights are displayed. Fire and disaster drill documentation is maintained, with the last drill conducted on 6/4/2026. (CONTINUED ON LIC 809-C)
Deborah Mullen
Tricia Danielson
DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
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 8
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)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852
VISIT DATE: 09/23/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(CONTINUED FROM LIC 809) There are three inground ponds at the facility. During today's inspection, the following was observed: There is a wooden 60 inch high fence preventing access to the backyard were the ponds are located. The vertical clearance from the ground to the bottom of the fence is greater than 2 inches; there are no gaps or voids which would allow the passage of a sphere with a diameter equal to or greater than four inches; there are no outside surface protrusions, cavities or other physical characteristics that would serve as a handhold or foothold enabling a child to climb over. LPA verified the gate opens away from the pond area but is not self-closing or self-latching. There is no pool alarm or pool cover for any of the ponds. There is no life ring or fixed 12-foot rescue pole with a body hook present at the facility. The licensee has not begun to maintain a daily pool inspection log to ensure all safety measures are in place before the facility open. Licensee Reyes now understands that all bodies of water including ponds, above ground pools, spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar products must be emptied immediately after use and stored in an upright position.
Both children's and employees' records are complete. Mandated Reporter Training has been completed and is valid until 7/2027 Pediatric CPR and First Aid certification expires on 5/2027. All adults requiring caregiver background checks have received the necessary clearances and exemptions.
Licensee Reyes 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 discussed the safe sleep regulations with Licensee Reyes and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee Reyes 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 LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Deborah Mullen
NAME OF LICENSING PROGRAM ANALYST: Tricia Danielson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852
VISIT DATE: 09/23/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(CONTINUED FROM LIC 809-C)
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) or (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 Reyes 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.
The Duty Officer is available to answer questions Monday – Friday 8:00 AM to 5:00 PM at (951) 782-4200. All Unusual Incident Reports can be submitted online at UnusualIncidentReportsDO10@dss.ca.gov.
Licensee Reyes confirmed that there are no registered sex offenders living in the facility and LPA completed the RSO profile in FAS.
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 for CARE tools, please send the 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/process.

There are deficiencies being cited on the attached LIC 809-D pages.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Licensee Reyes. Appeal Rights also were discussed and provided along with an LIC 9213- Notice of Site Visit which must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Deborah Mullen
NAME OF LICENSING PROGRAM ANALYST: Tricia Danielson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/23/2026 01:25 PM - It Cannot Be Edited


Created By: Tricia Danielson On 09/23/2026 at 12:40 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above. The gate entry to the backyard were the ponds are located was not self closing or self latching which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will ensure the gates in the backyard are self closing and self latching and submit proof to the department 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.
Deborah Mullen
NAME OF LICENSING PROGRAM MANAGER:
Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/23/2026 01:25 PM - It Cannot Be Edited


Created By: Tricia Danielson On 09/23/2026 at 12:40 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(A)(i)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (A) An enclosure, including, but not limited to, a fence, wall, or other barrier that isolates the swimming pool from access to the family daycare home and has all of the following characteristics: (i) An access gate that opens away from the swimming pool and is self-closing with a self-latching, key lockable device placed no lower than 60 inches above the ground.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above. The gate to the pond area did not have a key lockable device no more than 60 inches from the ground. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will ensure the gates to the pond areas have a keyed lockable device placed no more than 60 inches from the ground and submit proof to the department by the POC due date.
Type B
Section Cited
HSC
1596.814(a)(1)(A)(iii)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (A) An enclosure, including, but not limited to, a fence, wall, or other barrier that isolates the swimming pool from access to the family daycare home and has all of the following characteristics: (iii) A maximum vertical clearance of two inches from the ground to the bottom of the enclosure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The fence preventing access to the pond areas had a vertical clearance from the ground greater than 2 iches which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will ensure the fencing preventing access to the pond areas has a vertical clearance no greater than 2 inches from the ground and submit proof to the department 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.
Deborah Mullen
NAME OF LICENSING PROGRAM MANAGER:
Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/23/2026 01:25 PM - It Cannot Be Edited


Created By: Tricia Danielson On 09/23/2026 at 12:40 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (B) In addition to the characteristics described in subparagraph (A), at least one of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The ponds in the backyard were not covered with an approved cover or pool alarm which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will install an approved cover or pool alarm for each pond by the POC due date and submit proof to the department by the POC due date.
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The facility did not have an approved life ring available near the ponds in the backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will install a United States Coast Guard approved life ring measuring no less than 17 inches in diameter near the ponds in the backyard and submit proof to the department 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.
Deborah Mullen
NAME OF LICENSING PROGRAM MANAGER:
Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/23/2026 01:25 PM - It Cannot Be Edited


Created By: Tricia Danielson On 09/23/2026 at 12:40 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: REYES FAMILY CHILD CARE
FACILITY NUMBER: 376300852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The facility was not equipped with a 12' foot fixed length rescue pole with body hook. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The license will install a 12' fixed length rescue pole with body hook near the ponds and submit proof to the department by the POC due date.
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The licensee was not maintaining a daily pool (pond) inspection log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
1
2
3
4
The licensee will establish daily pond inspection procedures and maintain a log of such inspectionsn and submit proof to the department 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.
Deborah Mullen
NAME OF LICENSING PROGRAM MANAGER:
Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 8 of 8