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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209371
Report Date: 10/28/2025
Date Signed: 11/05/2025 10:45:28 AM

Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EVERGREEN COURTFACILITY NUMBER:
107209371
ADMINISTRATOR/
DIRECTOR:		ROYCHOUDHURY,MINAKSHIFACILITY TYPE:
740
ADDRESS:1415 WEST SCOTT AVENUETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:33 PM
MET WITH:Licensee/Administrator, Minakshi RoychoudhuryTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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On 10/28/25 Licensing Program Analysts (LPAs) M. Garza and M. Yang arrived at the facility to complete an unannounced annual visit. LPAs met with Care Giver, Santonsh Kumari, explained reason for visit and were permitted entry into the facility. Licensee/Administrator, Minakshi Roychoudhury was contacted and arrived some time later. LPAs completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 6 resident was present during visit observed in family room. 2 of 6 residents receiving hospice services and 1 of 6 receiving home health services.

Pathways and doors were clear and free from obstruction. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 09/11/25. Resident rooms observed to have the required furnishings and with adequate lighting. LPA observed sufficient seating under covered patio areas.

The following issues were observed during today’s visit: Chemicals observed under hallway sink unlocked and accessible. Peri care bottles observed in bedroom #3 unlocked and accessible. Chemicals unlocked and accessible under kitchen sink. Sharps accessible and not properly closed near stove. Chemical in first aid kit accessible. Nutritional supplements in pantry unlocked and accessible. Paint in bedroom #1, in living room unlocked and accessible. Medications unlocked and accessible. No orders for crushed medications for R2. Medications short for R1 (medication error). No appraisals for 1 of 6 residents. No needs and services plans for 2 of 6 residents. No medical consent forms for 2 of 6 residents. Records reviewed shows 2 of 6 resident went to hospital, facility did not report to CCL. CONT...

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371
VISIT DATE: 10/28/2025
NARRATIVE
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CONT...

No home health care plan for 1 of 6 residents. Records review, shows R6 has a stage 3 pressure injury. Walk in closet is locked and inaccessible to R6. Deficiencies cited per California Code of Regulations, Title 22. Deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct impact to the health, safety and/or personal rights of residents in care.

LPAs requested the following documents to be submitted to CCL by 10/31/2025: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with Licensee/Administrator, Minakshi. A plan of correction was developed by Licensee/Administrator and reviewed by LPAs. A copy of this report, deficiencies, and appeal rights were discussed and provided to Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited


Created By: Mary Garza On 10/28/2025 at 05:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 when LPAs observed at approximately 09:40AM, medications stored in kitchen cabinet unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 10/29/2025
Plan of Correction
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Staff immediately locked medication cabinet. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(1)
87465 (c)(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews conducted, the licensee did not comply with the section cited above when LPAs reviewed R2’s file and observed a handwritten note on a white blank printer paper without a physician’s signature for medication (Alprazolam 0.23 mg) and for crush medications, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/Administrator will obtain written order on a prescription order and/or physician company letter header by POC due date. Prescription orders for medication Alprazolam and crush medication will submit to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


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Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited


Created By: Mary Garza On 10/28/2025 at 05:25 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation and records reviewed, LPAs checked R1’s medications, R1’s MAR, and centrally stored medication list. R1’s Tamsulosin Hcl 0.4mg bubble pack filed on 09/29/25 was opened and administered 10/1/25. R1’s MAR record medication Tamsulosin administered daily at 08:00AM from 10/10/25 to 10/28/25. Medication was observed 1 medication Tamsulosin capsule left, which poses/posed an immediate health and safety risk for the person in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/Administrator shall submit a written statement providing the steps the facility will take to ensure that the residents’ medications are being administered as directed by the physician. The written statement shall be submitted to Fresno CCL office by POC due date 10/29/25.

All staff will be retrained again on in-service training on administering medications and documenting and recording medications when administered. In-service training includes documentation of training topics that was covered during in-service retraining, date the re-training was given, trainer’s full name with signature, number of hours of training was given, date and time the in-service retraining was given, and signature of staff who attended in-service retraining, will be submitted to the Fresno CCL office by 11/10/25.
Type A
Section Cited
CCR
87309(a)
87309(a)…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
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Based on observation, the licensee did not comply with the section cited above when LPAs toured the facility at approximately 09:34AM, Clorox disinfecting wipes under the hall bathroom sink unlocked, at 09:35AM, peri care wash bottles unlocked in bedroom #3, at 09:39AM multiple chemicals stored unlock under the kitchen sink, at 09:40AM, sharps in kitchen cabinet next to the stove not properly closed, 09:43AM eye wash solution packets and alcohol pads observed unlock in first aid kit in hallway and a box filled Ensure Max protein nutritional supplement unlock in pantry, at 09:48AM paints in a clear plastic bin on resident desk unlock, and approximately 11:09AM craft paints and a box of acrylic paints under and on top of desk in the livingroom all were accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/Administrator immediately locked chemicals and tools. POC cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited


Created By: Mary Garza On 10/28/2025 at 05:35 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(1)(a)
87615(a)(1) (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.

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 when LPAs reviewed R6’s file and observed notes in hospice plan of care dated 10/14/25 record R6 has Stage 3 wound to right buttock, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/Administrator will submit a written Plan of correction Fresno CCL by POC due date 10/29/25.
Section Cited
Deficient Practice Statement
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited


Created By: Mary Garza On 10/28/2025 at 05:37 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)
87506(b)(17) Documents and information required…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, all residents’ files were reviewed. An appraisal (Lic 603) and needs and services plan (Lic 625) was not observed in R2’s file, R3’s Lic 625 was not observed in R3’s file, Medical Consent form (Lic 627C) was not observed in R1 and R4’s files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee/Administrator shall ensure that all residents have the required records on file. R2’s Lic 603 and Lic 625, R3’s Lic 625, R1’s Lic 627C and R4’s Lic 627C will be completed and submitted the Fresno CCL office by POC due date 11/03/25.
Type B
Section Cited
CCR
87303(a)
87303 (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
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Based on observation, LPAs toured the facility and observed at approximately 09:50AM the air filter was observed full of thick dust in hallway near laundry room, at approximately 09:53AM multiples sacks filled with spiders eggs observed behind laundry room door, and at approximately 10:00AM the right side backyard fence board was broken and spider webs were observed, which poses/posed a potential health and safety and personal rights risk to the resident in care.
POC Due Date: 11/10/2025
Plan of Correction
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The facility shall be in good repair, clean, and sanitary by POC due date. Proof of repair of the backyard fence board, proof of air filter replaced, and proof of spider webs and sack eggs cleaned will be submitted to the Fresno CCL by POC due date 11/10/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 10:45 AM - It Cannot Be Edited


Created By: Mary Garza On 10/28/2025 at 05:40 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
87211(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement was not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review and interview conducted, LPAs reviewed the residents’ files and observed hospital discharge record for R5 recording R5 had gone to the hospital on 08/09/25 and R3 went to the hospital on 01/16/25. The department did not receive a written report when R3 and R5 went to the hospital, this poses a potential health and safety risk to residents in care.
POC Due Date: 10/31/2025
Plan of Correction
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Licensee/Administrator will review the Reporting Requirements regulation 87211 and a written policy and procedure will be in place to ensure the Reporting requirements are met. Written policy and procedure will be submitted to the Fresno CCL by the POC due date 10/31/25.
Type B
Section Cited
CCR
87609(b)(4)
87609 (b)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

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 when LPAS reviewed R1’s file, who’s currently receiving home health with no current home health care plan on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
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2
3
4
Licensee/Administrator will obtain R1’s current home health care plan and submit it to Fresno CCL by POC due date 10/31/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


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Created By: Mary Garza On 10/28/2025 at 05:42 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(13)
87468.1 (a)(13) To have access to individual storage space for private use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4

Based on interviews conducted and observation, the licensee did not comply with the section cited above when LPAs toured the facility at approximately 09:47AM, R6’s belongings was observed in bedroom 1 walk-in closet locked and only accessible to staff, which poses a potential health or personal rights risk to persons in care
POC Due Date: 10/28/2025
Plan of Correction
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2
3
4
Staff immediately unlock bedroom 1 walk in closet. POC cleared during visit.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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