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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200578
Report Date:
08/14/2024
Date Signed:
08/14/2024 08:34:53 PM
Document Has Been Signed on
08/14/2024 08:34 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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
ADMINISTRATOR:
OKEIGWE, OGEDI
FACILITY TYPE:
740
ADDRESS:
2957 HANNAN DRIVE
TELEPHONE:
(925) 947-5812
CITY:
PLEASANT HILL
STATE:
CA
ZIP CODE:
94523
CAPACITY:
6
CENSUS:
6
DATE:
08/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Winifred Wepee, Caregiver
TIME COMPLETED:
08:45 PM
NARRATIVE
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On 08/14/2024 at 3:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Winifred Wepee and explained the purpose of the visit. Winifred phoned Licensee/Administrator, Ogedi Okeigwe and informed. The facility’s fire clearance was approved for capacity six (6) non-ambulatory of which one (1) may be bedridden. Bedridden is granted for Bedroom #6. Hospice waiver for two (2). Administrator Certificate #6041025740 expires 09/01/2024.
LPA toured facility with Winifred including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.
Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/08/2024. Emergency Disaster Plan was last posted on 08/14/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/03/2024.
LIC809-C Continued...
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, record review, the licensee did not comply with the section cited above in by not reporting to the local fire dept that oxygen is in use for R1 in Bedroom #1 which poses an immediate health and safety risk to persons in care.
POC Due Date:
08/15/2024
Plan of Correction
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2
3
4
Administrator agree to submit a copy of letter to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
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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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review the licensee did not comply with the section cited above in by not having First Aid and CPR for S1 and S2 which poses a potential health and safety risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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Administrator agree to submit coppies of First Aid/CPR and/or health professional license/certification to CCLD by POC date.
Type B
Section Cited
CCR
87533(e)(2)
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having S6, S7 and S8 associated to facilicity in Guardian which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2024
Plan of Correction
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Administrator agree to submit LIC9182 with valid U.S. issued picture ID to CCLD by POC 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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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 by not having 20x26 poster sized PUB 475 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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Administrator agree to submit a photo to CCLD by POC 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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
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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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having an updated Physician's report for R1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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Administrator agree to submit an updated Physician's Report (LIC602A) for R1 by POC date.
Type B
Section Cited
CCR
87463(a)(3)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having an updated Appraisal Needs and Services (ANS) Plan for R1 which poses a potential health and safety risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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Administrator agree to submit an updated ANS for R1 to CCLD by POC 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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
5
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in by not having updated review of Emergency Disaster Plan LIC610E (P.9) signed and dated which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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Administrator agree to submit copy of updated reviewed LIC610E to CCLD by POC date. While at the facility S2 updated and signed LIC610E. Deficiency cleared.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having doctor's orders on file for R2-R4,R6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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2
3
4
Administrator agree to submit copies of doctor's orders for 1/2 rail beds for R2-R4,R6 to CCLD by POC 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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
6
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Document Has Been Signed on
08/14/2024 08:34 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having an doctor's order for R1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
1
2
3
4
Administrator agree to submit an copy of doctor's order for hospital bed for R1 to CCLD by POC date.
Type B
Section Cited
CCR
87616(b)(2)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following: (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having an exception request for R1's foley catheter which poses a potential healt and safety risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
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2
3
4
Administrator agree to submit an exception request for foley catheter with all supporting documents to CCLD by POC date. Deficiency will not be cleared until all documents are received and approved.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
7
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Document Has Been Signed on
08/14/2024 08:34 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having an updated Physician's Report for R2 which poses a potential health and safety risk to persons in care.
POC Due Date:
08/28/2024
Plan of Correction
1
2
3
4
Administrator agree to submit updated Physician's Report for R2 to CCLD by POC 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.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
8
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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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
CORDIAL CARE HOME
FACILITY NUMBER:
079200578
VISIT DATE:
08/14/2024
NARRATIVE
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LPA reviewed six (6) residents records. LPA reviewed 8 staff records and 6 of 8 have current first aid training and 5 out of 8 were associated to the facility.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/21/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Copy of Liability Insurance Policy
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/14/2024
LIC809
(FAS) - (06/04)
Page:
18
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