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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601105
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:07:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211207111332
FACILITY NAME:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 3DATE:
05/10/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lead Caregiver, Ganalyn DavidTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff do not wear masks
Facility did not provide a bedroom for resident
Facility did not assist resident with self-administration of medication as prescribed
Staff did not regularly observe resident for change in condition
INVESTIGATION FINDINGS:
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On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn David and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui over the phone and explained the purpose of today's visit.

Regarding allegation of- staff do not wear masks, during the 10-day initial visit on 12/14/2021, LPA was greeted by staff #1 (S1) at the entrance who was not wearing a mask and after LPA's reminder, S1 immediately went to get a mask and put it on.

Based on observation, this allegation is substantiated.

Regarding to allegation of- facility did not provide a bedroom for resident, during the initial 10-day visit, LPA observed two beds in the big/living room, positioned in "L" shape. According to the Staff #2 (S2), the facility has sufficient number of bedrooms for all the residents. However the 2 female residents who were supposed to be sharing a room did not get along so in order to separate them, the facility empty a bedroom that was occupied by 2 male residents and moved them into the big/living room. Also, S2 stated that the 2 male residents would eventually go back to their bedroom when one of the female residents goes home but S2 did not have the discharge date for this female resident.

Based on observation and interview during the course of investigation, this allegation is substantiated as the facility violated the Personal Accommodations and Services of the 2 male residents to accommodate the 2 female residents.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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Regarding the allegation of- facility did not assist resident with self-administration of medication as prescribed, the reporting party stated that the facility failed to assist Resident #1 (R1) with pain medication as ordered by the physician.

According to Staff #3 (S3), R1 asked for pain medication in the middle of the night, and S3 did not feel comfortable of given it to R1 so S3 asked R1 to wait for S2 to give it in the morning as S2 was sleeping at the time.

According to R1's hospital medical record, R1 has an order for Acetaminophen (Tylenol) every 6 hours as needed for pain. During an interview with S2, S2 stated that facility did not give R1 any pain medication during the time of R1's stay.

Based on interviews and record review during the course of investigation, this allegation is substantiated as the facility did not give R1's pain medication as prescribed by the physician.

Regarding to allegation of- staff did not regularly observe resident for change in condition, the complainant reported that the facility did not observe and check R1's blood sugar level as ordered by the physician which resulted R1's blood sugar rose to 282.

According to Administrator, the facility did not conduct a pre-admission appraisal of R1 prior to R1's admission, therefore, the facility was not aware that R1 required blood sugar checks every 4 hours and then insulin injections accordingly until R1's responsible party informed the facility of such needs after R1's admission.

In addition, the facility failed to conduct a pre-admission appraisal to ensure R1 is suitable for the facility. Furthermore, during the course of investigation, LPA observed injections and blood sugar finger stick checks for the resident who was not capable of performing it by themselves were administered by a facility staff who was not a skilled professional . These deficiencies will be cited on LIC809 and LIC809D.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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Based on R1's hospital documentation provided, R1 has Insulin Lispro Sliding scale 6 times a day with specific times and physician's order for insulin injection but the facility was not aware of these orders as the facility failed to conduct a pre-admission appraisal prior to R1's admission.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with administrator(over the phone), caregiver and Appeal Rights provided.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful...
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The administrator and/or designee shall provide in-services to facility staff on the importance of following the mandated mask protocol. The administrator and/or designee will provide a copy of the sign-in records
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This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed staff #1 was not wearing any face covering which posed an immediate health and safety risks to resident in care.
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 to CCL by 5/12/2022.
Type A
05/12/2022
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical,...When changes such as...physical health condition are observed, the licensee shall ensure that such changes are documented and
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The administrator will review this regulation and provide a copy of a signed statement acknowledging of the review and understanding to CCL by 5/12/22.
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brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: the facility failed to observe R1's blood sugar level which posed an immediate health and safety risks to resident in care.
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The administrator will provide in-services to staff on the importance of Observation of the Resident and provide a copy of the education sign-in record to CCL by 5/12/22.
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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care...(a)A plan for incidental medical... shall be developed by each facility..(4) The licensee shall assist residents with self administered medications as needed.
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The administrator/Licensee will validate all staff are trained on assisting residents with their prescribed medication. Afterwards, the administrator or the licensee will submit a statement to CCL of such validation by 5/12/22.
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This requirement was not met as evidenced by: the facility failed to assist R1's pain medication during the night upon R1's request as prescribed by R1's physician posed an immediate health and safety risks to resident in care.
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In addition, the administrator and/or designee will provided in-service to facility staff on assisting resident's medication at all times as prescribed and provide a copy of the facility staff sign-in record to CCL by 5/12/22/
Type A
05/12/2022
Section Cited
CCR
87307(a)(2)(B)
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87307 Personal Accommodations and Services..(a)Living accommodations...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents...(2)Resident bedrooms shall be provided which meet..(B) No room commonly used for
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The administrator or licensee should review this regulation and provide a statement of acknowledgment to CCL by 5/12/22.
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other purposes shall be used as a sleeping room for any resident. This requirement was not met as evidenced by: the facility moved 2 male residents who were sharing a room into the living room to accommodate a female resident who did not get along with her roommate which posed an immediate health and safety risks to resident in care.
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In addition, the administrator shall develop a plan to avoid this situation from happening again and provide a copy of the plan to CCL by 5/12/22.
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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 11 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211207111332

FACILITY NAME:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 3DATE:
05/10/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lead Caregiver, Ganalyn DavidTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility does not maintain hand sanitizer
Staff did not assist resident with incontinence care
Facility is malodorous
Facility did not ensure that resident's medication was maintained at facility
Staff speaks inappropriately to resident
INVESTIGATION FINDINGS:
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On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui on the phone and explained the purpose of today's visit.

Regarding allegation of- facility does not maintain hand sanitizer, during the initial inspection tour, LPA Han observed bottles of hand sanitizers at these locations: by the entry screening station, in the kitchen, in the living room, in the bathroom and extra hand sanitizers in the storage room. According to staff #3, the facility has always maintained hand sanitizers.

Based on observation and interview during the course of investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of staff did not assist resident with incontinence care, the Reporting Party stated that R1 was not provided incontinence care during R1's stay.

LPA interviewed facility staff and residents. The facility staff denied the allegation and stated that R1 was changed several times during R1's stay and in general, they checked the residents every 4 hours for incontinence care and other needs.

LPA interviewed the residents who appeared to be cleaned and neatly dressed and they stated that they are being checked, and changed for incontinent care routinely and when needed.

Based on interviews and observation during the course of the investigation, this allegation is deemed to be unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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Regarding allegation of facility is malodorous- during the initial inspection, the staff provided a tour of the resident's rooms, living room, the big room, kitchen, dining room and the bathrooms. LPA observed facility was cleaned, tidy and odorless. According to the facility staff, they clean the facility every day and the residents also stated that the facility is cleaned and their rooms are being cleaned daily.

Based on interviews and observation during the course of investigation, this allegation is deemed to be unsubstantiated.

Regarding allegation of - facility did not ensure resident's medication was maintained at the facility, the Reporting Party stated that R1 brought pain medication to the facility upon admission but the facility could not find it during R1's discharge. LPA interviewed staff #2 (S2) and they denied the allegation and stated that upon R1's discharge, all the medication was taken by the Responsible Party who was present at the time. In addition, LPA observed the medication storage cabinet and did not find any medications with R1's name on it. Furthermore, LPA interviewed the other residents regarding to their experience of medication storage, and they stated they have not experienced their medication being missing.

Based on interviews during the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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Regarding allegation of- Staff speaks inappropriately to resident, the Reporting Party stated that facility staff yelled at R1 when R1 asked for assistance. The facility staff denied the allegation and stated they never yelled at R1 and other residents. According to S3, R1 was ringing the bell very loudly for assistance during the night and S3 was very close to R1 so S3 asked R1 to not ring the bell so loudly as S3 did not want the sound of the bell to wake up other residents. As part of the investigation, LPA interviewed 2 others residents and both of them stated that the facility staff never yelled at them, they are attentive to their needs and respectful while speaking to them.

Based on interviews during the investigation, this allegation is deemed to be unsubstantiated.

Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2021 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20211207111332

FACILITY NAME:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 3DATE:
05/10/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lead Caregiver, Ganalyn DavidTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility does not ensure that supplies are available to provide care for resident's health condition
Facility is operating over capacity
Staff do not ensure that staff and residents are socially distanced
INVESTIGATION FINDINGS:
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On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui over the phone and explained the purpose of today's visit.

Regarding to allegation of- facility does not ensure that supplies are available to provide care for resident's health condition, the reporting party stated that the facility attempted to use a baby wipe to clean resident #1(R1)'s finger in preparation of conducting a blood sugar check instead of an alcohol wipe. According to Staff #2 (S2), the facility has plenty of alcohol wipes and LPA observed ample supply of alcohol wipes in the storage cabinet.

Based on interview and observation during the course of investigation, this allegation is deemed to be unfounded.

Regarding to facility is operating over capacity, during the initial 10-day visit, S2 stated that facility has 6 residents and during the toured of the facility, LPA validated that there were 6 residents at the facility which was the approved/licensed capacity.

Based on observation and interview during the course of investigation, this allegation is deemed to be unfounded.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 14-AS-20211207111332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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Regarding allegation of- staff do not ensure that staff and residents are social distanced, the reporting party stated it was not staff who were not socially distanced from the resident, rather it was resident to resident as R1's bed was attached to resident #2 (R2)'s bed in the big room.

Based on the above clarification information provided by the reporting party, this allegation is deemed to be unfounded.

In addition, During the 10-day initial complaint visit, LPA observed R1 and R2's beds were positioned in a "L" shape and there were a table in between the 2 beds. Although the beds were not 6" apart, the facility did follow the head - to - toe orientation.

Based on this investigation, this complaint allegations are determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with administrator (over the phone) and lead caregiver.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 11