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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200923
Report Date: 12/13/2025
Date Signed: 12/13/2025 05:42:00 PM

Document Has Been Signed on 12/13/2025 05:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELLE'S HOMEFACILITY NUMBER:
019200923
ADMINISTRATOR/
DIRECTOR:		ROCERO, MARIA CARMELAFACILITY TYPE:
740
ADDRESS:2420 COLUMBINE COURTTELEPHONE:
(510) 470-3681
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
12/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Maria Carmela 'Marla' Rocero/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
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On this day, December 13, 2023, at 10:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted Geca Bronken, staff. LPA called and spoke over the phone with 'Marla' Rocero, administrator (ADM), and informed the reason for visit. LPA also met with other staff, Rebecca Go. ADM arrived at 11:42 am with other staff, Noel Rocero..

LPA started the inspection with Rebecca Go ad Geca Bronken and continued with ADM. LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested, and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 111.7 degrees Fahrenheit. Facility conducts disaster drills quarterly, and records showed last conducted December 5, 2025. Fire extinguisher checked, and tag showed serviced December 2, 2025.

LPA reviewed 4 staff and 5 residents files, and interviewed 3 residents. Medications checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.


.....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2025
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923
VISIT DATE: 12/13/2025
NARRATIVE
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LPA observed the following:
-at 10:58 am, moldy grapes, expired yogurt and sour cream, rotten cabbage and eggplant, tortilla not properly stored (plastic package open), and unlocked medications in the refrigerator.
-at 11:00 am, soiled kitchen rug and dirty kitchen floor.
-at 11:07 am, unlocked cabinet under the sink where Comet and WD-40 were kept with casseroles and cutting board.
-at 11:10 am, very dirty and rusty oven toaster, bread toaster and rice cooker.
-at 11:11 am, dirty and moldy dish drainer, greasy cooking range and range hood.
-at 11:12 am, medications in the dining area.
-at 11:14 am to 11:30 am, cobwebs and spiders all through out the facility.
-at 11:22 am, medication in one of the resident's rooms.
-at 11:24 am, perineal cleanser, scissors, Calmoseptine ointment in unlocked bathroom cabinet
-at 11:31 am, hole on the wall, dusty lights and air vents, moldy shower area/floors in 2 bathrooms, rusted shower curtain bars in the common bathrooms.
-at 11:39 am, broken and dirty closet door in another residents' room. Moldy ceiling, spider and cobwebs in this residents' room and bathroom.
-cameras that capture audio in all residents' rooms.
-at 11:49 am, medications in the refrigerator in the backyard porch.
-at 11:50 am, hammer, Miracle gro fertilizer and moldy chairs in the backyard.
-at 11:51 am, overgrown weeds about 2 ft tall, rusted metal shelf, crates, piece of metal in the side yard.
-at 2:15 pm, staff (S2) only completed 26 hours of the 40 hours required training.
-residents' (R2, R3 and R4) half bed rails do not have doctor's orders on file.
-resident (R3) has Senna medication but no doctor's order on file. Facility has prescriptions for other 4 (ointments, Glycol, patch) but facility does not have them.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2025
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923
VISIT DATE: 12/13/2025
NARRATIVE
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Administrator to submit updated/current copies of the following documents by December 27, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/13/2025 at 04:06 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: unlocked medications in the refrigerators; unlocked cabinet under the sink where Comet and WD-40 were kept; perineal cleanser, scissors, Calmoseptine ointment in unlocked bathroom cabinet; medications in the dining area and resident's room; hammer and Miracle gro fertilizer in the backyard
POC Due Date: 12/14/2025
Plan of Correction
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Administrator locked the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/24/25.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having casseroles and cutting board stored where Comet and WD-40 are kept which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 12/14/2025
Plan of Correction
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Administrator removed the casseroles and cutting board.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/24/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 12/13/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/13/2025 at 04:06 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 the following which pose an immediate health and/or personal rights risks to persons in care: moldy grapes; expired yogurt and sour cream; rotten cabbage and eggplant; tortilla not properly stored
POC Due Date: 12/14/2025
Plan of Correction
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Administrator have all the items discarded.
In addition, administrator to in-service the staff and submit copy of training topics with attendees signatures by 12/24/25
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(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 residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

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 not having doctor’s order for R3's Senna medication and not having the other 4 listed on the order which pose an immediate health and/or personal rights risks to person in care.
POC Due Date: 12/14/2025
Plan of Correction
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Administrator stated she'll obtain doctor's order for Senna and check with the doctor and obtain discontinued order for the other 4 if no longer needed. Proof to be submitted by 12/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 12/13/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/13/2025 at 04:06 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risk to persons in care: cobwebs and spiders all through out the facility; hole on the wall, dusty lights and air vents in the batrooms; moldy ceiling; broken and dirty closet door in another residents' room; overgrown weeds, rusted metal shelf, crates, piece of metal, moldy chair in the yard
POC Due Date: 12/27/2025
Plan of Correction
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Administrator to do the following and submit pictures by 12/27/25:
1. Have the facility cleaned inside out.
2. Have the closet door fixed and cleaned.
3. Have the wall repaired/fixed.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on oservation, the licensee did not comply with the section cited above in dirty kitchen floor and moldy shower area/floor which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 12/27/2025
Plan of Correction
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3
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Administrator to have the kitchen floor and bathrooms thoroughly cleaned and submit pictures by 12/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 12/13/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/13/2025 at 04:06 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which a potential health, safety and/or personal rights risks to persons in care: dirty and moldy dish drainer; greasy cooking range and range hood; dirty and rusty oven toaster, bread toaster and rice cooker
POC Due Date: 12/27/2025
Plan of Correction
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2
3
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Administrator stated and will do the following. Pictures to be submitted by 12/27/25:
1. Have the cooking range and range hood cleaned.
2. Discard the dish drainer, oven toaster, bread toaster and rice cooker, and purchase new one.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) ... Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having doctor’s orders for R2, R3 and R4’s half bed rails.which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 12/27/2025
Plan of Correction
1
2
3
4
Administrator stated she'll obtain doctor's order. Copies to be submitted by 12/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 12/13/2025 05:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/13/2025 at 05:27 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELLE'S HOME
FACILITY NUMBER: 019200923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.269(a)(2)
§1569.269 Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the internet, and meetings of resident and family groups.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having cameras that capture/ have audio feature which pose a potential personal rights risk to persons in care.
POC Due Date: 12/27/2025
Plan of Correction
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2
3
4
Corrected.
Administrator removed the cameras.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2025


LIC809 (FAS) - (06/04)
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