434408192-10-29-2026-07-CC-FRAA-DZBV8F-20261029161239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408192
Report Date: 10/29/2026
Date Signed: 10/29/2026 04:13:20 PM

Document Has Been Signed on 10/29/2026 04:13 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KAENI, SIMIN		FACILITY NUMBER:	434408192
ADMINISTRATOR/ DIRECTOR:	KAENI, SIMIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 891-2556
CITY:	SARATOGA	STATE: CA	ZIP CODE:	95070
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 7	DATE:	10/29/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Simin Kaeni		TIME VISIT/ INSPECTION COMPLETED:	04:20 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	On 10/29/2026, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced annual inspection. LPA was granted access to the home by Licensee and explained the nature of today’s inspection. Present in the home were licensee, two adult assistants and seven children including one infant and six preschool age. Licensee was observed to be operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Friday, 8:00 AM to 4:30 PM. LPA observed all required posted materials in the sun room of the home. Per licensee, two adults and no minor children reside in the home. LPA toured the indoor and outdoor areas of the home with Licensee during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture, children's toys and napping equipment was observed to be in good condition. The home has central heating/cooling and ventilation for comfort of children. Licensee stated that they use a wall mounted air conditioner and portable heater to maintain a comfortable temperature for children in the sun room. The home is single story. Off limit areas inside the home is the attached garage. LPA observed a wood stove in the sun room that is barricaded with a child gate. LPA observed an infant in a crib with a small comfort blanket/lovey. LPA reminded Licensee that loose items, blankets and sleep sacks cannot be placed inside the crib when infants are napping. The nap room for the infant is through a door from the dining area that leads to the door of the nap room. The nap room door was observed to be ajar but the door leading to the nap room was observed to be closed. LPA reminded Licensee that If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door. Continued on Page 2

Gladys Kuizon
Farida Raja
	DATE: 10/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 10/29/2026

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

LPA observed a 3A40BC fire extinguisher and working smoke and carbon monoxide detector in the sun room. LPA reminded licensee that fire extinguisher needs to be serviced once every 12 months and service tag or receipt of purchase needs to be maintained for review. Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, poisons, medications, sharp objects and other similar items were observed to be stored inaccessible to children. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

Outdoor space and play equipment were observed to be age appropriate. Children use the outdoor area to the right and left side of the sun room. Backyard is fenced and both sides of the home are gated. Off limit areas outdoors includes: fenced swimming pool area and storage shed (right side area). Shade was observed to be provided by building overhang, umbrellas, trees and canopy.

LPA observed the swimming pool and jacuzzi are surrounded by a metal fence that is atleast 60 inches. The fence does not obscure the pool from view. The mesh fence has a maximum vertical clearance of two inches from the ground to the bottom of the enclosure, no gaps or voids that can allow the passage of a sphere with a diameter equal to or greater than four inches. The access gates leading to the swimming pool swing away from the pool, self-close with a self-latching device that is no more than six inches from the top of the gate. LPA observed, per HSC 1596.814 effective January 1, 2025, the swimming pool and jacuzzi have a pool alarm that is compatible with the ASTM International Standard, a life ring with minimum of 17 inches in diameter and labeled as approved by United Stated Coast Guard, a rescue pole with a body hook and minimum length of 12 feet. The pool alarm was tested during today's inspection. Upon testing the alarm in the swimming pool LPA noted that there was a delay of a few minutes before the alarm sounded. LPA advised Licensee to fix the delay to ensure that the alarm sounds as soon as an object falls inside.

Licensee is not conducting and maintaining a log of the daily inspection of the drowning prevention safety features and safety equipment before opening the facility each day as required.

Bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free of hazards. LPA reminded Licensee that toothpaste, shampoos, air fresheners, disinfecting sprays/wipes, razors, mouthwash, perfumes and similar items need to be placed inaccessible to children in care.

Continued on Page 3

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 10/29/2026

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

Licensee was reminded to notify the Department before making any alterations or additions to the home or grounds and when any change from an area of the family child care home previously identified as off limits is changed to an area where care and supervision will be provided to children in care.

Drinking water is readily available for children in the home via individual water bottles and refilled using store bought water. Licensee states that she provides morning and afternoon snacks to the children and parents provide lunch from home. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated.

LPA reviewed a current children's roster and fire drill log during today's inspection. Fire drill was last conducted on 08/12/2026 within is within the 6-month requirement for facilities. LPA obtained copy of children's roster. Licensee carries daycare insurance and LPA verified current policy.

LPA reviewed a sample of five children’s files and observed files were complete with emergency information as required. Licensee is not conducting and maintaining a 15-minute sleep log for two infants in care. LPA reminded Licensee that 15-minute checks need to be conducted for all infants and record for logs needs to be maintained for review.

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-and-resources/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.

LPA reviewed three staff files (Licensee and two adult assistants) for the required forms. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee has current Pediatric CPR/First Aid certification which expires on 09/10/2027. Licensee and staff have the required immunization in file for measles, pertussis and influenza/statement declining influenza. Licensee and one staff, S2 have not renewed the Mandated Reporter Training for Child Care Workers. LPA reminded Licensee that the training needs to be renewed every two years.

Continued on Page 4

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 10/29/2026

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

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.

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.

LPA discussed "zero tolerance" related regulations which includes the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA discussed the Community care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations, Provider Information Notices (PINs) and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Incidental Medical Services (IMS) policy was discussed. Licensee states that no children require medications or IMS at this time. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Licensee states that a child will be isolated in the living room if necessary due to illness or communicable disease until authorized representative pick up. 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/.

Continued on Page 5

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
	VISIT DATE: 10/29/2026

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

Licensee understands that children's personal rights should not be violated; including no corporal punishment. Children have personal rights that cannot be waived or abridged regardless of consent or authorization from the child’s authorized representative. LPA advised Licensee that children should not be left for extended periods of time in furniture such as a high chairs or cribs.

Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.

Per Title 22, Division 12, of the California Code of Regulations, four Type B deficiencies and two technical violations were issued.

Exit interview conducted and report was reviewed with Licensee, Simin Kaeni. During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Appeal rights provided.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

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.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 10/29/2026 04:13 PM - It Cannot Be Edited

Created By: Farida Raja On 10/29/2026 at 03:16 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee is not conducting and maintaining a log of the daily inspection of the drowning prevention safety features and safety equipment before opening the facility each day as required.
	POC Due Date: 11/30/2026
	Plan of Correction
1 2 3 4	Licensee to maintain a daily inspection log and submit proof of completed log from 10/30/2026 until 11/30/2026 to LPA by plan of correction date of 11/30/2026.

Type B

Section Cited

CCR

102425(j)(5)(A)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The nap room door was observed to be ajar but the door leading to the nap room was observed to be closed.
	POC Due Date: 11/30/2026
	Plan of Correction
1 2 3 4	Licensee to review safe sleep regulations and submit a written plan of correction to LPA by 11/30/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:

	Farida Raja
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 10/29/2026 04:13 PM - It Cannot Be Edited

Created By: Farida Raja On 10/29/2026 at 03:16 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KAENI, SIMIN	FACILITY NUMBER: 434408192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee and one staff, S2 have not renewed the Mandated Reporter Training for Child Care Workers. LPA reminded Licensee that the training needs to be renewed every two years.
	POC Due Date: 11/30/2026
	Plan of Correction
1 2 3 4	Licensee to submit certificate of completed training for herself and staff to LPA by 11/30/2026.

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

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: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee is not conducting and maintaining a 15-minute sleep log for two infants in care.
	POC Due Date: 11/30/2026
	Plan of Correction
1 2 3 4	Licensee to conduct and maintain a 15-minute log and submit proof of completed log from 10/30/2026 until 11/30/2026 to LPA by plan of correction date of 11/30/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:

	Farida Raja
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2026

LIC809 (FAS) - (06/04)

Page: 8 of 8