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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804038
Report Date: 05/02/2025
Date Signed: 05/02/2025 03:45:28 PM

Document Has Been Signed on 05/02/2025 03:45 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR/
DIRECTOR:		MCDANIEL, JUANITAFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(707) 526-1808
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 4CENSUS: 2DATE:
05/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:44 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. LPA contacted licensee Jenero Jefferson by telephone. Jenero informed LPA that facility has an Administrator now, he named I4 as being the new Admin and that he would be sending me all the paperwork "right now." LPA spoke to I4 and they advised they are not 21 years old yet. LPA called licensee back but received voicemail. LPA left voicemail indicating an Administrator is required to be at least 21 years old and have a current and active ARF Administrator certificate. I4 has completed course work but has yet to receive their certificate. LPA checked Administrator certificate Pending list but I4 not on it. LPA advised licensee of such and so there is actually not currently an Administrator for the facility (deficiency cited, see 809D).

Also, upon LPA arrival, LPA learned that S1's family is living here as of April 13, 2025: I1, I2, I3, and I4. Sometimes I5 visits I4 here at the facility now that I4 lives here. LPA checked Guardian for fingerprint clearance for I1, I2, I4, and I5. I3 is a minor child. I5 not present during LPA visit and is not living at facility. However, I1 and I2 do not have fingerprint clearance (deficiency cited, see 809D and civil penalty assessed). LPA advised S1 that I1, I2, and I5 cannot be present in any capacity at the facility until fingerprint clearance is granted. Per I4, I4 only lives here, they are not currently providing any care to the residents. I4 does have fingerprint clearance and is associated to another facility. LPA advised S1 they are not associated to the facility. LPA advised if I4 does start providing care to the residents they will also need to be associated. S1 advised LPA that they do not have access to Guardian themselves to associate. LPA advised to send LIC9182 to LPA for themselves and I4 along with their IDs and CCL will associate them. S1 advised LPA that they are int he process of buying the home, but does not currently have an application submitted to CCL for a license. S1 plans to

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
VISIT DATE: 05/02/2025
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Continued from 809...

continue having the home be an ARF. LPA advised that once the sale is final, please let LPA know. Once sale is final S1 will lease the facility to the current licensee. LPA advised that current licensee Jenero Jefferson will still be responsible for all matters regarding the operation of the facility until such time that there is a Change Of Ownership (CHOW) completed through CCL.

At approximately 10:00am LPA toured the building and grounds. The facility was found to be at a comfortable temperature. LPA did not observe at least a 2 day supply of perishable and 7 day supply of non-perishable food. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Medication is stored in a closet, LPA found door unlocked and medication accessible to residents. Additionally, medication tablet found in facility unlocked office in bubble pack accessible to residents. (deficiency cited, see 809D).

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Master bedroom unlocked. bleach and laundry soap present in bath of master bedroom accessible to residents (deficiency cited, see 809D). Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar but had community towels LPA asked S1 about community towels. S1 advised they ran out of paper towels but asked licensee to buy more. Licensee has yet to provide more paper towels (deficiency cited, see 809D). Water temperature in sink accessible to residents in care measured at 109.8 degrees F in the kitchen and 110.7 in the bathroom, which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 3/19/24 but is showing as charged. Smoke/Carbon Monoxide detectors located throughout the facility are operational. Facility’s last quarterly disaster drills were not executed and/or documented (deficiency cited, see 809D).

At approximately 12:35pm LPA conducted a review of two [2] resident records. R1 did not have a physician's report or medical assessment (MA)on file. S1 helped LPA look for R1's MA but could not locate one (deficiency cited, see 809D). Per S2, R1 was recently seen at the doctor, but for a bone density test. Both R1 and R2 did not have a current appraisal or IPP/ISP on file (deficiency cited, see 809D).

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
VISIT DATE: 05/02/2025
NARRATIVE
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At approximately 1:00pm LPA conducted review of three [3] staff records. S1 and S3 did not have TB clearance, S2 did not have Health Screen (deficiency cited, see 809D). S1 and S3 had expired First Aid (deficiency cited, see 809D)

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 03:45 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/02/2025 at 02:54 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that master bedroom unlocked. bleach and laundry soap present in bath of master bedroom accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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2
3
4
Facility to submit LIC9098 self- certifying they will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients by POC due date
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation and caregiver interview, the licensee did not comply with the section cited above in that I1 and I2 do not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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2
3
4
Facility to submit LIC9098 self-certifying all those residing at the facility have fingerprint clearance by POC 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 03:45 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/02/2025 at 02:54 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above inthat facility does not currently have an Administrator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Facility to submit required documents for individual that will be the Administrator by plan of correction due date. Documents to include: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, copy of Admin certificate, and board resolution from the corporation.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S3 1st Aid/CPR exp 4/21/25, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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2
3
4
Facility to submit plan to have S1 and S3 complete1st Aid/CPR certification. Certification to be completed no later than 5/12/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 03:45 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/02/2025 at 02:54 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above inthat R1 did not have a medical assessment on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
1
2
3
4
Facility to submit plan to have R1's current medical assessment completed. Current medical assessment for R1 by no later than 5/12/25.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that Medication is stored in a closet, LPA found door unlocked and medication accessible to residents. Medication tablet found in facility unlocked office in bubble pack accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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2
3
4
Facility to submit LIC9098 self-certifying that medication shall be kept in a safe and locked place that is not accessible to residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 03:45 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/02/2025 at 02:54 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the licensee did not comply with the section cited above in that common towels were present, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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2
3
4
Facility to purchase/supply papertowels and ensure common towels. Receipt for papertowels in a quantity that is enough for all residetns and staff to use to be submitted by plan of correction due date.
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that facility’s last quarterly disaster drills were not executed and/or documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
1
2
3
4
Facility to conduct disaster drills on each shift for all staff by plan of correction due date. Documentation of completed drills to be submitted by plan of correction 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


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Created By: Christi Coppo On 05/02/2025 at 03:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above in that S1 and S3 did not have TB clearance, S2 did not have Health Screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
1
2
3
4
Facility to submit Tb clearance for S1 and S3 and Helath Screen for S2 by plan of ocrrections due date.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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