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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601134
Report Date: 01/20/2026
Date Signed: 01/21/2026 09:32:48 AM

Document Has Been Signed on 01/21/2026 09:32 AM - 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SUNSHINE CARE HOME FACILITY LLCFACILITY NUMBER:
415601134
ADMINISTRATOR/
DIRECTOR:		ROXANNE EDUARTEFACILITY TYPE:
740
ADDRESS:2976 FLEETWOOD DRIVETELEPHONE:
(650) 720-1441
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 4DATE:
01/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Caregiver, Fernando "Don" GonzalezTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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On January 20, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers, Rodolfo Castalone and Fernando "Don" Gonzalez and LPA explained the purpose of today's visit. Caregiver called and informed the administrator, Roxanne Eduarte of LPA's inspection.

LPA toured the facility's building and grounds. This is a two level home. Upper level is for facility care staff and 1st floor is for residents. There are 4 bedrooms (2 shared and 2 private) for the residents and 2 full bathrooms. All rooms for residents are non-ambulatory. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 108-110 degrees F. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

LPA observed sharps, medication, toxins and chemical were unlocked and accessible to residents.

Facility is equipped with smoke detectors and carbon monoxide detectors. .

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2026
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 9
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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Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed knife and chemicals were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff re-education. The completion date of the re-education shall be no later than 1/28/2026. The plan shall also include what is the plan that the administrator/licensee shall develop to ensure this does not happen again. The administrator/licensee will provide a copy of the plan to CCL by 1/21/2026.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 did not have a health screen in the personnel file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure S1 completes a health screen and the completion date shall be no later than 1/28/2026. The plan shall also include what is the plan that the administrator/licensee shall develop to ensure this does not happen again. The administrator/licensee will provide a copy of the plan to CCL by 1/21/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 and S2 did not complete their annual training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance. The plan shall include the completion date of the annual training for S1 and S2 and the date shall be no later than 1/28/2026. The plan shall also include what is the plan that the administrator/licensee shall develop to ensure this does not happen again. The administrator/licensee will provide a copy of the plan to CCL by 1/21/2026.
Type A
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance. The plan shall include the completion date of the self-medication administration training for S2 and other staff who assists with medication. The completion date of training shall be no later than 1/28/2026. The plan shall also indicate what is the plan that the administrator/licensee shall develop to ensure this does not happen again. The administrator/licensee will provide a copy of the plan to CCL by 1/21/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 and S2 did not complete their annual training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance. The plan shall include the completion date of the annual training for S1 and S2 and the date shall be no later than 1/28/2026. The plan shall also include what is the plan that the administrator/licensee shall develop to ensure this does not happen again. The administrator/licensee will provide a copy of the plan to CCL by 1/21/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2, R3 and R4 did not have an updated reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance. The administrator/licensee shall provide a copy of an updated reappraisal for R2, R3, and R4 and a copy of the plan of correction to CCL by 1/28/2026. The plan of correction shall indicate what is the plan to ensure this does not happen again.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed emergency drills were not completed accordingly, they were completed in Jan 2025, May 2025 and Dec 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and the plan of correction shall indicate what is the plan to ensure this does not happen again. The administrator will provide a copy of the plan of correction to CCL by 1/28/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in as the facility was not able to provide proof that the emergency disaster plan was reviewed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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2
3
4
The administrator/licensee will develop a plan to ensure compliance and will provide proof that the emergency and disaster plan was reviewed. The plan of correction shall also indicate what is the plan to ensure this does not happen again. The administrator/licensee will provide a copy of the plan of correction to CCL by 1/28/2026.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134
VISIT DATE: 01/20/2026
NARRATIVE
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The following documents were requested submitted to CCL by :1/28/2026:
- Liability Insurance
- LIC500

During today's visit, LPA observed repeat citations that were made from the previous annual inspections in January 2024, December 2024 and today. The citations were resident's reappraisals were not updated, staff annual training was not complete and emergency drills were not conducted accordingly.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with caregivers.

A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 01/21/2026 09:32 AM - It Cannot Be Edited


Created By: Murial Han On 01/20/2026 at 12:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNSHINE CARE HOME FACILITY LLC
FACILITY NUMBER: 415601134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(c)


This requirement is not met as evidenced by:87405 Administrator - Qualifications and Duties

(c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility.
Based on observation, and record reviews, the facility has recieved several same citations during the annual inspections on 1/2024, 12/2024 and 1/2026
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility has received several same citations during the annual inspections on 1/2024, 12/2024 and today's inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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2
3
4
The Licensee shall develop a plan of correction to ensure the administrator is educated and qualified to carry-out and to implement all the licensing requirements. The Licensee will provide a copy of the plan of correction to CCL by 1/21/2026.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
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