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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609832
Report Date: 07/16/2026
Date Signed: 07/16/2026 09:15:31 PM

Document Has Been Signed on 07/16/2026 09:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BLISSFUL HOMEFACILITY NUMBER:
567609832
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:962 GILL AVETELEPHONE:
(805) 253-0452
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
07/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH: Virginia FarinTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:00 A.M. The LPA met with Facility Designee, Virginia Farin, and explained the reason for the visit. Administrator on file, Arlene Martinez, was contacted via telephone. Administrator was unavailable during today's visit, but authorized Facility Designee, Virginia Farin, to sign today's reports. Entrance interview conducted.

Beginning at 11:15 A.M., the LPA, along with Facility Designee, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Facility is a two-story residence, the upstairs area is inaccessible to residents in care and is used for staff only, therefore it was not observed. Fire extinguisher was fully charged with purchase date of 06/01/2026. Hardwired smoke and carbon monoxide detectors were tested at 12:15 P.M. and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional during the visit.

BEDROOMS: There are four (4) total resident bedrooms in the facility; two (2) are designated as private resident rooms and 2 (two) are designated as shared rooms. All residents’ rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The bedrooms were large enough to allow for easy passage. Bedridden bedroom #1 and bedroom #4 have exits to the exterior and attached bathrooms. LPA observed that facility is retaining bedridden residents in a room which is designated as non-ambulatory. Additionally, one resident was using supplemental oxygen; however, "No Smoking – Oxygen in Use" signage was not present in areas where oxygen was in use. Technical Violation (TV) issued.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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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Document Has Been Signed on 07/16/2026 09:15 PM - It Cannot Be Edited


Created By: Valeria Conway On 07/16/2026 at 03:49 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

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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Based on observation and record review, the licensee did not comply with the section cited above as the facility is retaining bedridden residents in a room which is designated as non-ambulatory which poses an immediate safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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Facility designee agreed to transfer resident from room #4 to room # 1 as room #1 has clearance to retain one bedridden resident.
Type A
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 measured above the required range which poses an immediate safety risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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During today's visit boiler was adjusted and water measured within required range. POC Cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/16/2026 09:15 PM - It Cannot Be Edited


Created By: Valeria Conway On 07/16/2026 at 03:49 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above as Administrator on record is not present at the facility during normal working hours which poses a potential safety risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Administrator shall be present at least 20 hours a week or submit paperwork assigning another person to take over administrator duties. A statement of understanding on this regulation or new administrator's paperwork shall be submitted to LPA before POC due date.
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as medication logs were missing start dates which poses a potential health and safety risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Facility Designee will write a statement of understanding regarding this regulation and update the medication log. Documentation will be sent to LPA prior to 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/16/2026 09:15 PM - It Cannot Be Edited


Created By: Valeria Conway On 07/16/2026 at 03:49 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one resident did not have a TB test result on file which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Test results will be sent to LPA prior to POC due date
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as multiple reappraisal were not signed and/or current which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Signatures will be collected for missing reappraisals and a new updated reappraisal will be conducted for R1. All documentation will be submitted to LPA prior to 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/16/2026 09:15 PM - It Cannot Be Edited


Created By: Valeria Conway On 07/16/2026 at 03:49 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the only drill conducted was for earthquake and fire since 2019 which poses a potential safety risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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A list of new drills will be submitted to LPA before POC due date and those mentioned drills will be conducted quarterly.
Type B
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 and record review, the licensee did not comply with the section cited above as R4 had bed rails that extended the length of the bed and they are not currently receiving hospice services which poses a potential personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Bed rails will be removed and 1/2 rails will only be present if R4 has a Drs order.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 07/16/2026
NARRATIVE
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Continued from LIC 809

BATHROOMS: There are 3 (three) total resident bathrooms, of which two (2) are inside resident rooms. Restrooms were observed clean with slip resistant mats, and grab bars by the showers and toilets. LPA observed that toilet located in bedroom #1 was not functioning properly as it was not flushing due to a leak. Technical Violation (TV) issued. All other toilets were in working condition. The water temperature was measured in the bathroom inside room #1 and #4 and measured 121.5 and 122.0 degrees Fahrenheit.

KITCHEN: LPA inspected the kitchen at 11:45 A.M. Knives are locked in a toolbox that’s kept on the kitchen counter. Cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:00 P.M. the hot water temperature measured 125.6 degrees Fahrenheit.

COMMON AREAS: This includes the living room, dining area, and office room. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed storage space closets in hallway containing clean linens for resident use. The required postings were observed throughout the common spaces. Activities were observed stored in the living room. The fireplace was adequately screened. There is a functioning telephone on the premises.

OUTDOOR SPACE/GARAGE: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. LPA observed a shed containing yard tools and extra mobility supplies and two (2) self-closing side gates. LPA toured the garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply and an additional pantry for extra food.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 07/16/2026
NARRATIVE
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Continued from LIC 809-C

RECORD REVIEW: Facility records are stored in a locked cabinet in the office room. The LPA reviewed six (6) resident files and six (6) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. The LPA observed the following: Resident 1 (R1) Physician’s report indicates that the resident is ambulatory, however, during today’s visit, LPA observed that R1 is non-ambulatory, also they did not have a current appraisal/needs and service plan on file and they were missing their Tuberculosis (TB) test result. Residents’ 2, 3 and 4 (R2,3&4) current appraisal/needs and service appraisal did not have signatures. Furthermore, LPA observed Resident’s 4 (R4’s) bed rails that extended the entire length of the bed; however, they are not currently receiving hospice services. All staff records were in order. The LPA reviewed the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the facility’s current liability insurance, and last emergency disaster drill. Last drill was conducted on 06/08/2026. LPA observed that facility is conducting the required quarterly emergency drills; however, a review of drill records indicated that since 2019 staff have only participated in earthquake and fire drills. LPA explained that emergency preparedness training should include a variety of disaster scenarios to ensure staff and residents are prepared to respond appropriately to different types of emergencies.

MEDICATION REVIEW: Medications are locked in a cabinet in the office room. Medications for two (2) residents were observed. Medications are labeled and checked for expiration dates. Facility receives a pre-generated Centrally Stored Medications and Destruction Record (CSMR) from the pharmacy where staff only need to document the start date. During review, LPA was unable to verify whether the exact medication dosage was administered as the facility did not record start dates on the Central Stored Medication Destruction Records (CSMDR). Additionally, LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 07/16/2026
NARRATIVE
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Continued from LIC 809-C

INFECTION CONTROL: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. Resident interviews revealed that Administrator is not present at the facility during normal working hours and it is negatively affecting the facility’s daily operations.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided. An immediate civil penalty in the amount of $500 is being assessed on today’s date sue to a fire clearance violation.

Exit interview, a copy of the report and Appeal Rights was provided to the facility designee.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
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