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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334808838
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:07:35 PM

Document Has Been Signed on 07/24/2025 03:07 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KINDERCARE LEARNING CENTERFACILITY NUMBER:
334808838
ADMINISTRATOR/
DIRECTOR:		IVAMAE HANEYFACILITY TYPE:
830
ADDRESS:1655 HIDDEN VALLEY PARKWAYTELEPHONE:
(951) 898-5677
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 24TOTAL ENROLLED CHILDREN: 17CENSUS: 12DATE:
07/24/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Director IvaMae HaneyTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/24/2025 at 10:34 AM Licensing Program Analysts (LPAs) Susan Brewer and Laura Mejorado arrived at the facility for the purpose of conducting and annual inspection. This is a combination center with 3 component programs. The LPAs were greeted and granted entry by Director Ivamae Haney and Assistant Director Reyna Gonzalez to tour the infant center, inside and out. The following was observed:

The inspection consisted of reviews of the following domains: Food Service; Reporting Requirements
Physical Plant; Care and Supervision; Children Records; Staff Records; Staffing Ratio and Capacity and Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted on the LIC809-D.

The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days if changes have been made:
1. LIC 500 Personnel Report - Requested
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization
5. LIC 308 Designation of Administrative Responsibility
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838
VISIT DATE: 07/24/2025
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The following items have been posted and are updated where necessary:
License; Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
Parent’s Rights Poster (PUB393); Personal Rights (LIC613A); Child Car Seat Law; Menu
· The facility is operating within the terms of the license.
· Facility is clean, safe and sanitary and in good repair.
· Appropriate supervision and Ratios were met during this inspection with 5 staff and 12 children.
· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.
· Rooms and activity areas are physically separated from other components.
· Rooms are equipped with age-appropriate furniture and equipment in good condition
· Uncontaminated drinking water is provided in both the indoor and outdoor activity areas by public water supply and filtered water, tap water, bottled water, water pitchers, individual water bottles and disposable cups.
· Napping equipment is sufficient for capacity and meets licensing requirements.
· Rooms are clean and free of hazards
· Materials and surfaces accessible to children are toxic free.
· No weapons stored at the facility.
· There are no bodies of water present on today’s date. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Medications are stored where inaccessible to infants: Located in a locked box in the kitchen.
· Center is equipped to isolate and care for any child who becomes ill during the day.
· Toxins are locked and Hazards are stored where inaccessible to infants.
· Toileting area was observed to be safe, sanitary and in operating condition.
· Outdoor play area is physically separated by appropriate fencing and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· There is sufficient cushioning material under high climbing equipment, swings, slides and similar equipment: Natural Grass, Rubber turf and shaded area.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838
VISIT DATE: 07/24/2025
NARRATIVE
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· Measures are taken to keep the facility free of flies, other insects and rodents.
· Food preparation area is clean and free of vermin on today’s date.
· Food is stored appropriately and protected from contamination.
· All storage containers for solid waste have tight-fitting covers that are kept on, and in good repair
· Individual feeding and Infant needs and service plans were reviewed and are complete for each individual infant and up to date.
· Infants up to 12 months shall have a sleeping plan as required with documentation of date, name, time of 15-minute check, however incomplete due to full names not documented, some staff initials were missing and checks were missing status of children during naptime to include sleep position, breathing, temperature, skin color and/or observation of sleep status.
· Infant files were reviewed and are NOT complete: One child missing the LIC701 Physician’s report, 3 of 5 files reviewed missing sign in/out records and have incomplete records; 3 of 5 files have incomplete LIC9227 Individual Sleep plans
· Sign in/Sign out record was reviewed and do NOT meet regulation requirements. Incomplete records and missing records.
· A Staff member is present with current Pediatric CPR/First Aid which expires on 07/2026.
· Opening and closing staff member’s CPR/First Aid expires on 07/2026.
· Asst. Director completed Health and Safety Training on SP2003; Missing Nutrition and Lead; Director missing proof of training.
· Staff qualifications and files were reviewed and are NOT complete: 1 staff present missing LIC503 Health Screening/TB; 1 staff missing Tdap.
· Staff have received on the job training for housekeeping, sanitation and universal health precautions
· Documentation of fire & earthquake drills to be conducted every six months: Last fire drill on 06/23/2025 at 9:58 AM; 79 children present, lasted 23 minutes
· Documentation of Lead Testing is on file: Test Results 12/08/2022, No lead exceedances.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838
VISIT DATE: 07/24/2025
NARRATIVE
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· A review of staff records on 07/24/2025 indicates NOT all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. A subject staff present and supervising infants during the inspection was not associated to the facility.

The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov, Licensee was informed of the Department has inspection authority per Health and Safety Codes.

AB2370 – Lead Exposure, day care facilities, effective January 1, 2019 –
The bill requires that all Child Care Centers, operating in a building constructed before January 1, 2010, shall have their drinking water tested for excessive lead levels, on or after January 1, 2020, but no later than January 1, 2023. Child Care Centers must thereafter test their drinking water every five years after the date of the initial test.
AB605 – Child day care facilities, birth to school-age license; Effective January 1, 2021

AB2960 – Child care and development services, online portal – Effective June 20, 2022 - This bill requires the State Superintendent of Public Instruction (SSPI), within the California Department of Education (CDE), to develop and post on CDE's website a comprehensive child care and development services online portal for families and providers by June 30, 2022.

Please subscribe at www.childcareadvocatesprogram to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. Duty Officer is available to answer questions Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766).



This facility provides Incidental Medical Services – IMS. LPA Susan Brewer, reviewed storage for medication and equipment/supplies and administrative records. No infants on IMS plan at this time. For IMS information, see PIN 22-02-CCP.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838
VISIT DATE: 07/24/2025
NARRATIVE
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A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Director Ivamae Haney was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with Director Ivamae Haney and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to Inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Deficiencies were cited this visit for Type B violations. Civil Penalties were not issued this visit
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with Director Ivamae Haney.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 07/24/2025 03:07 PM - It Cannot Be Edited


Created By: Susan Brewer On 07/24/2025 at 01:47 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 in a 1 staff present did not have proof of Pertussis and all staff were missing proof of influenza or letter to decline the influenza, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The licensee agrees to ensure a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year; and submit proof of missing documentation to the department by fax, mail or e-mail.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in a staff present and working with children did not have proof of a LIC503 health screening or Tuberculosis screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The licensee agrees to ensure a staff are in good physical health, verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure; and submit proof of missing health screenings with tuburculosis screenings by fax, mail or e-mail.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Susan Brewer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 03:07 PM - It Cannot Be Edited


Created By: Susan Brewer On 07/24/2025 at 01:47 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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 in 3 children present did not have complete sign in/out records and were missing sign in/out records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The licensee agrees to ensure the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day; and submit proof of corrected sign in/out records missing for children by fax, mail or email.
Type B
Section Cited
CCR
101217(a)(14)
101217(a)(14) Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (14) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 101170(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in a staff present to care and supervise infants was not associated to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
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The licensee agrees to ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (14) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 101170(e); to associate all employees or rehires to the facility and send proof of documentation of staff present to the department by fax, mail or e-mail.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Susan Brewer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 03:07 PM - It Cannot Be Edited


Created By: Susan Brewer On 07/24/2025 at 02:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 334808838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220a
101220a Child’s Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 in a subject child present in care did not have proof of the LIC701 Physician's Report, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The licensee agrees to ensure Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child and submit proof of the LIC701 Physician's report to the department by fax, mail or e-mail.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Susan Brewer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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