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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202756
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:16:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231114122603
FACILITY NAME:SUNSHINE VILLA ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
445202756
ADMINISTRATOR:MCKIE, JAMESFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:132CENSUS: 102DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Candi BolinTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not ensure that resident is administered their medication(s) as prescribed.
Staff do not respond to resident(s) requests for assistance in a timely manner.
INVESTIGATION FINDINGS:
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On 9/11/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation findings. LPA met with General Manager (GM) Candi Bolin and explained the purpose of the visit.

On 11/14/2023, the Department received a complaint with the above allegations. On 11/20/2023, the Department conducted an initial investigation visit. LPA interviewed the Health Service Director, Resident Care Director, Facility Nurse, 4 staff, a resident and a resident's family. LPA requested resident's physician report, appraisal needs and service plan, physician orders, and medication administration records.

On 2/16/2024, the Department conducted an investigation visit. 4 staff and 5 residents were interviewed. LPA requested call button log, POA in health and financial documents, resident medications document, medications training log, communication logs, Medication Administrations Records (MAR), resident physician reports, email communications, and resident vital sign chart document.

page 1 of 5
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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Staff do not ensure that resident is administered their medication(s) as prescribed:
The facility was alleged that the facility staff delivered the wrong insulin to resident R1 for the bedtime medications on 11/09/2023, around 8:00PM.

From 11/19/2023 to 3/8/2024, the Department conducted investigation including interviews with residents and staff, records reviewed and touring of the facility. On 11/19/2023 and 11/2023, LPA interviewed resident R1’s family member (FM). FM stated he/she received a phone call from R1 on 11/09/2023 at 9:00PM that the facility staff delivered the wrong insulin to R1 and R1 was waiting for the correct insulin to be delivered to R1’s bedroom.

On 11/20/2023, LPA interviewed resident R1. R1 stated on 11/09/2023 evening, the facility staff delivered the insulin for meals to him/her, and he/she told the staff that it should be a long-acting insulin for the bedtime medications. R1 stated he/she waited for long time and the staff brought back the correct long-acting insulin for his/her bedtime medications, then he/she injected the insulin by self.

On 11/20/2023 and 11/25/2023, LPA interviewed 8 staff. 2 staff (S1, S2) stated there was an incident that the wrong insulin was delivered to R1 for the bedtime medications on 11/09/2023 evening around 8:00PM.

On 2/16/2024, LPA interviewed 4 staff. 2 staff (S3, S4) stated the facility staff delivered incorrect insulin to resident R1 on 11/09/2023 evening.

On 2/25/2024, LPA interviewed staff S1. S1 stated he/she delivered the same insulin as R1’s insulin for dinners (the fast-acting insulin) to R1 on 11/09/2023 around 8:00PM and R1 found the insulin was wrong. S1 stated he/she changed the wrong insulin to the long-acting insulin and delivered to R1 later, and R1 injected the long-acting insulin for the bedtime medications.

Reviewing R1's doctor prescription dated 10/19/2023 which specifies fast-acting insulin to administer to R1 15 minutes before breakfast, lunch, and dinner, and long-acting insulin to administer to R1 at bedtime.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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Based also records review of R1s progress notes, there were instances where the wrong insulin was given to R1 for administration. Said dates are 1/1/2024 & 1/3/2024.

Based on a review of R1's doctor orders and interviews, the facility staff delivered the wrong insulin to R1 on 11/9/2023 evening. Facility staff did not ensure to deliver resident's medications as prescribed.

Staff do not respond to resident(s) requests for assistance in a timely manner:
The facility is alleged that the facility staff delivered the wrong insulin to resident R1 on 11/09/2023 around 8:00PM for R1’s bedtime medications and R1 found the insulin was wrong. R1 told the staff that the bedtime insulin was wrong, and the staff stated he/she would bring the correct insulin back later. But R1 was waiting for more than one hour to get the correct insulin on 11/9/2023 between 9:00Pm – 9:30PM.

On 11/19/2023 and 11/20/2023, LPA interviewed resident R1’s family member (FM1). FM1 stated R1’s scheduled insulin bedtime medication time is 7:30PM. FM1 stated on 11/09/2023, the facility staff delivered the wrong fast-acting insulin to R1 for the bedtime medications and R1 found the insulin was wrong. FM1 stated R1 called the front desk more than one time that R1 was waiting for the correct insulin to deliver to him/her. FM1 stated he/she called the facility on 11/9/2023 at 9:00PM that R1 was waiting for the correct insulin. FM1 stated the facility delivered the correct long-acting insulin by 9:30PM.

On 11/20/2023, LPA interviewed R1. R1 stated his/her scheduled insulin for bedtime medications is 7:30PM. R1 stated on 11/9/2023, he/she found the staff delivered the wrong insulin for his/her bedtime medications, and the staff stated he/she will double check and bring the correct insulin. R1 stated he/she waited for long time and called the facility two times that he was waiting for the correct insulin.

On 11/24/2023, LPA interviewed staff S1. S1 stated on 11/09/2023 at 8:00PM, he/she delivered the fast-acting insulin to R1 for R1’s bedtime medications. S1 stated after he/she finished delivering medications to other residents, he/she delivered the correct long-acting insulin to R1 around 8:45PM on 11/9/2023 for R1’s bedtime medications.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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On 2/16/2024, LPA interviewed staff S4. S4 stated on 11/09/2023 between 8:30PM - 9:00PM, he/she received a phone call from R1 that R1 was waiting for the correct insulin. S2 stated he/she received a phone call from R1's family member around 9:00PM on 11/9/2023 that R1 was waiting for the correct insulin, and between 9:00PM - 9:30PM, he/she received another phone call from R1 that he/she was waiting for the correct insulin.

On 2/25/2024, LPA interviewed staff S1 regarding the time he/she returned to R1's bedroom and administration of the correct insulin for bedtime. S1 stated he/she was unable to remember the exact time because it was long time ago. S1 stated on 11/09/2023 roughly between 8:30PM to 9:30PM that he/she delivered the long-acting insulin to R1 and R1 injected self.

Reviewing R1's doctor order dated 10/19/2023, which specifies long-acting insulin to administer to R1 at bedtime. But it did not specify the exact time to administer the insulin for bedtime. R1’s physician order dated 11/20/2023 which specifies starting on 10/22/2023 to administer long-acting insulin for R1’s bedtime medications at 8:00PM.

Based on the records reviewed and interviews, from R1’s the first oral request for the correct insulin and through several calls from R1 and R1’s family, it took more than one hour for the facility to deliver the correct long-acting insulin to R1 on 11/09/2023 evening which did not meet R1’s health needs.

The Department has investigated the above allegations. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview was conducted with GM. This report and LIC9099-D were provided to GM for signature. A copy of the report and appeal rights was provided to GM.


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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
CCR
87411(a)
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87411 - Personnel Requirements - (a) Facility
personnel shall at all times be sufficient in
numbers, and competent to provide the
services necessary to meet resident needs.
This requirement was not met as evidenced by:
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Licensee has already submitted POC to LPA regarding in-service training about insulin and medication management.
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Based on interviews and records reviewed,
staff S1 was not competent or lacked training to deliver/administer correct insulin to residents based on doctor's prescription. This poses health and safety risks to residents in care.
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Type B
09/18/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents...(a) In addition to the rights ... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee has already submitted POC to LPA regarding in-service training about insulin and medication management.
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This requirement was not met as evidenced by: Based on the interviews and records reviewed, the facility staff took longer than one hour to administer the correct insulin to R1.The facility does not have sufficient staff or staff lack training to provide care to residents in care.
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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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231114122603

FACILITY NAME:SUNSHINE VILLA ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
445202756
ADMINISTRATOR:MCKIE, JAMESFACILITY TYPE:
740
ADDRESS:80 FRONT STREETTELEPHONE:
(831) 459-8400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:132CENSUS: 102DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Candi BolinTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not respond to resident's request(s) for communication in a timely manner.
Staff do not ensure that resident's representative is able to participate in decisionmaking regarding the care and services to be provided to the resident while in care.
INVESTIGATION FINDINGS:
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On 9/11/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced investigation visit to deliver the investigation findings. LPA met with General Manager (GM) Candi Bolin and explained the purpose of the visit.

On 11/14/2023, the Department received a complaint with the above allegation. On 11/20/2023, the Department conducted an initial investigation visit. LPA interviewed 7 staff, 4 staff, a resident and resident's family. LPA requested resident's physician report, appraisal needs and service plan, physician orders, Medication administration records.

On 2/16/2024, the Department conducted an investigation visit. 4 staff and 5 residents were interviewed. LPA requested call button log, POA in health and financial documents, resident medications document, medications training log, communication logs, Medication Administrations Records (MAR), resident physician reports, email communications, and resident vital sign chart document.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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Staff do not respond to resident's request(s) for communication in a timely manner:
The facility is alleged that the facility staff did not respond to the email sent by resident R1’s family member (FM1) for R1 to request a meeting with appropriate health service staff in a timely manner.

A review of the email communication between Resident Care Director (RCD) and FM1 between 11/09/2023 and 11/14/2023. The email was sent out by FM1 to the facility Resident Care Director, Health Service Director (HSD) and the facility Nurse on 11/09/2023 Thursday at 10:40PM to request a meeting with the facility health service staff and to have FM1 present in the meeting.

On 11/12/2023, Sunday, at 3:49PM RCD replied to FM1’s email that he/she already met with R1 one on one on 11/12/2023 and replied and explained to FM1 about FM1’s concerns in the email. The email RCD also reveals RCD’s conversations/advice/recommendations with R1.

On 11/13/2023 at 1:51PM FM1 replied to RCD’s email with the questions why RCD had an unscheduled meeting with R1 without FM1 and ignored R1’s requesting a meeting and to have FM1 present.

On 11/14/2023, at 9:30AM, RCD replied to FM1 via email that RCD called FM1 and had a conversation on 11/14/2023 at 9:25AM that RCD would like to set up a in person meeting with R1 and FM1 but without success. RCD provided his/her phone number for FM1 to contact RCD when FM1 ready to have a meeting.

On 11/20/2023, LPA interviewed HSD, RCD and facility Nurse. RCD’s working hours is Sunday 9:00AM – 6:00PM to Thursday 9:00AM – 6:00PM. The working hours of HSD and the facility Nurse are Monday 9:00AM – 5:00PM to Friday.

RCD stated the first day he/she came back to the office, 11/12/2023 around 1:10PM, he/she met with R1 because R1 complained received insulin late. RCD stated he/she and FM1 had email communication on 11/12/2023 and 1/13/2023. RCD stated on 11/114/2023 at 9:25AM he/she called FM1 and had a conversation to set up a meeting but without success. RCD stated he/she sent email to FM1 on 11/14/2023 at 9:30AM and leaving his/her phone number for FM1 to call to set up a meeting. But did not get any response from FM1.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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On 2/16/2024, LPA interviewed the general manager (GM). GM stated the facility had R1’s evaluation meeting with FM1’s signature on 12/29/2023.

Based on the records reviewed and interviews, the facility staff did not follow up resident R1's request for a meeting and the facility had a care plan meeting with R1 and R1's representative one month after R1's requesting meeting with the facility staff, but R1 already spoke to RCD in person on 11/12/2023.

Staff do not ensure that resident's representative is able to participate in decision making regarding the care and services to be provided to the resident while in care:
The facility is alleged that the facility staff did not notify resident R1’s representative to present in R1’s care plan/service meeting on 11/12/2023.

On 11/20/2023, LPA interviewed Resident Care Director (RCD). RCD stated on 11/14/2023, at 1:10PM, he/she happened to see R1 at the front desk complaining about he/she did not get insulin at 12:15PM. RCD stated he/she explained to R1 that staff might sometimes arrive late, like around 12:30PM, because there are some instances that other residents might cause staff delays. RCD also provide some advice and recommendation to R1 that R1 should reduce the consummation of sweet snacks because his/her blood sugar fluctuates.

RCD stated R1’s care plan/service plan did not change, and the conversion and advice were emailed to FM1 around two hours later. RCD stated during the conversation with R1, R1 did not ask FM1 to present.

On 2/16/2024, LPA interviewed Health Service Director (HSD). HSD stated the facility always notifies resident representatives to attend resident’s care conference meeting.
HSD stated if there is a time conflict for resident representatives, then the facility will reschedule the meeting.

LPA interviewed general manager (GM). GM stated the facility always invite resident representative to join the care conference meeting. GM provided evidence of R1's care plan/service plan meeting with R1's family member FM's signature on 12/29/2023.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 26-AS-20231114122603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: SUNSHINE VILLA ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 445202756
VISIT DATE: 09/11/2024
NARRATIVE
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A review of R1’s progressive notes, on 11/12/2023, RCD met with resident R1 because R1 complained about did not getting insulin at 12:15PM. RCD replied to R1’s complaint and provided the explanation and provided some education and recommendation. There was no change in the care plan/service plan.

Based on the interviews and records reviewed, there was no change in R1's care plan/service plan on 11/12/2023. There was no any decision was made regrading R1's care plan/service plan when the facility met with R1 on 11/12/2023. R1 did not ask FM1 to present when the facility staff met with R1 on 11/12/2023 afternoon.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted. Exit interview conducted with GM. The report was provided to GM for signature. A copy of this report was provided to GM.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9