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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294284
Report Date: 05/20/2026
Date Signed: 05/20/2026 07:09:17 PM

Document Has Been Signed on 05/20/2026 07:09 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ST. MARY'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435294284
ADMINISTRATOR/
DIRECTOR:		ARIMAS, MARILUZ & MERLINOFACILITY TYPE:
740
ADDRESS:1265 SOCORRO AVENUETELEPHONE:
(408) 390-4931
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 5DATE:
05/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Marcelina Aniciete & Dolores Domingo & Mariluz ArimasTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage building, which is locked and inaccessible. There are 5 client bedrooms, two full bathrooms, one staff bedroom--with 2 beds--living/dining room, and kitchen. Clothes washer and dryer are located in two car garage. The backyard is level, fenced and mostly paved. Medications are secured in locked cabinet in kitchen. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested in bathroom. A comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Perishable and non-perishable fruits, vegetables and protein are maintained, as well as supplies of bed and bath linens and hygiene products. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Client files are reviewed, including Centrally Stored Medications Records.
Mariluz Arimas (x 11/26), Merlito Arimas (x 9/26) and Mialynn Arimas (x 12/27) are certified RCFE administrators that oversee facility operations.

The following licensing forms are requested to be completed and submitted to CCLD BY 6/3/26:
- Emergency Disaster Plan (LIC610)
- Personnel Report (LIC500)

Proof of current liability insurance is given to LPA today.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Note--8 pages.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
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 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on ob) (intervieion, the licensee did not comply with the section cited above, as facility has fire clearance for 6 non-ambulatory clients, but client #4 in room #5 is deemed to be BEDRIDDEN per MD. Facility does not have fire clearance for bedridden residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2026
Plan of Correction
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Plan/proof of correction to be sent to CCLD B Y DUE DATE
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 5 residents observed, which poses an immediate health, safety or personal rights risk to persons in care.
- Two half bed rails are used for clients #1, #3, #5
POC Due Date: 05/21/2026
Plan of Correction
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Bed rails will be reduced to only half rails, not 2 half rails. Lower half bed rails for Client #1 could not be removed in LPA's presence.
Proof of correction to be sent to CCLD BY 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 102 degrees in bathroom, which which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2026
Plan of Correction
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Hot water temperature to be increased and maintained within range of 105 and 120 degrees.
Proof of correction to be sent to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Staff #1 started working this month, but health screening is dated in 2024.
POC Due Date: 06/03/2026
Plan of Correction
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Current health screening and TB test result for staff #1 to be sent to CCLD BY 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on review of staff training records, the licensee did not comply with the section cited above, as staff #1 has ot received required initial training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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4
Proof of required training for staff #1 to be sent to CCLD BY 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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2
3
4
Based on review of staff training records, the licensee did not comply with the section cited above, as there is no record that staff received this annual training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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2
3
4
Proof of required training will be sent to CCLD BY DUE DATE
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on review of staff training records, the licensee did not comply with the section cited above, as there is no record that staff received this annual 4 hours of training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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2
3
4
Proof of required training to be sent to CCLD BY 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 05:49 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on review of staff training records, the licensee did not comply with the section cited above, as there is no record that staff received annual medications training,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
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2
3
4
Proof of required medications training for staff will be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above, as hospice care plan for client #1is not maintained, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2026
Plan of Correction
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2
3
4
Hospice Care plan for client #1 will be maintained and copy will be sent to CCLD BY 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2026 07:09 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2026 at 06:14 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. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. MARY'S RESIDENTIAL CARE HOME II
FACILITY NUMBER: 435294284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
INCIDENTAL MEDICAL CARE
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on medications review, the licensee did not comply with the section cited above in [1 out of 2 clients' medications reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Albuterol Rx filled 7/12/25 and Acetaminophen Rx filled 3/3/25 for client #3 are not logged in Centrally Stored Medications Record
- Medications are not logged in CSMR upon receipt
- Atorvastatin 100# Rx filled 3/3/25 is logged 2x on CSMR with start dates 3/4/25 and 4/13/26 and 26 pills counted today--staff are giving 2 pills/day, but Rx label & instructions are to take 1/day
POC Due Date: 06/03/2026
Plan of Correction
1
2
3
4
Plan of correction to be sent to CCLD BY DUE DATE to address medication administration discrepancies.
Albuterol and Acetaminophen were logged on CSMR in LPA's presence.
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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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