<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593040
Report Date: 11/01/2024
Date Signed: 11/01/2024 05:59:46 PM

Document Has Been Signed on 11/01/2024 05:59 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SCHREIBER FAMILY DAY CAREFACILITY NUMBER:
191593040
ADMINISTRATOR/
DIRECTOR:		SCHREIBER, NANCYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 263-1145
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
11/01/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Nancy Schreiber TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/01/2024 at 12:40 pm, Licensing Program Analyst (LPA), Carolyn Tuba conducted an unannounced inspection visit for the above facility. Covid risk assessment was conducted. LPA entered home through the front door which has a patio/Atrium area and then you enter through another front door. The facility is a large family childcare. LPA met with Licensee, Nancy Schreiber. LPA observed 8 children in care during today’s visit. Licensee stated that she currently has 11 children enrolled at this time.

LPA consulted about age groups and ratio and provided Licensee with Bananas Handout, which discusses how many children can be cared for at one time, as well as an Unusual Incident Report (UIR) for reference.

During the visit at 12:45 pm, LPA observed 2 baby saucers chairs but did not have any children in them. LPA advised Licensee that those could not be used, and they were removed. At approximately 12:50 pm an infant child who is under 2 years old was observed sleeping in a play yard and was using a Dock-Atot Snuggle-Me sleeper and had a pacifier attached to the infant’s shirt. Licensee stated that parent had asked to use the Snuggle-me sleeper, but LPA explained that nothing can be in the play yard or crib with the infant while they are sleeping. LPA consulted with Licensee and explained that the Snuggle-me sleeper was not allowed, and pacifiers are allowed when the infant sleeps but requires to be detached from child’s clothing. LPA provided Licensee the safe sleep documentation and Title 22 regulations.

Family members residing in the home are 1 adult (criminal record clearance on file) and no children. This is a one-story home which consists of 3 bedrooms, 2 bathrooms, daycare room, living room, dining room, kitchen, garage, front yard, back yard enclosed, and side yard is separated by a chain-link fence from the back yard and a cover patio/Atrium area that is located in the front of the house and has a locked door.

page 1 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 11/01/2024 05:59 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/01/2024 at 04:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

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 LPA observed Snuggle Me Sleeper from Dock-Alot infant was sleeping on the snuggle sleeper which has a bumper pad around the child which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Licensee removed snuggle sleeper and will return to parent. LPA consulted with Licensee regarding safe sleep.
Type A
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

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 pacifier and strap was attached to the infant's shirt which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Licensee removed the strap from the infant's shirt and LPA consulted safe sleep and that the pacifier may used but requires the strap be unattached from the clothing before child's is placed to sleep.
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/01/2024 05:59 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/01/2024 at 04:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in Licensee states that she is conducting emergency drills but is not documenting which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee will be conducting an emergency drill and document and provide to LPA.

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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 11/01/2024 05:59 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/01/2024 at 04:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 Mandated Reporter training expired August 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
1
2
3
4
Licensee will be completing training and providing a copy of the certificate to LPA.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 CPR/1st Aid expired on 3/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
1
2
3
4
Licensee will complete the Pediatric CPR/1st Aid EMSA approved and provide proof of completion.
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 11/01/2024 05:59 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/01/2024 at 04:14 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home 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
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in Licensee could not provide proof of her Tdap immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
1
2
3
4
Licensee will check with her physician for immunization records or have the Tdap immunization completed and provide proof to the LPA.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 Individualized Infant Safe Sleep Plan was not available in the (1) child's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee will have child's parent complete form and provide form to LPA.
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A facility roster was available. Per Licensee, operating hours are from Monday-Friday 7:00 am – 5:00 pm and cares for children ages 6 weeks to 13 years of age.

Licensee states that all meals are provided by the parents except for PM snack, and she does not use a food program at this time. Formula and baby food is provided by parents and LPA advised items must be labeled with child’s name and stored appropriately.

Areas used by children were inspected include: Living room, daycare room, 3 bedrooms, 1 bathroom, backyard. Back yard has bikes, play structure and children’s toys. – Rose bushes were observed and either require to be removed or surrounded by a gate by 11/12/2024. Bedrooms are used for children to sleep and bedroom #1 is used for ill child.

Per Licensee areas off limits include: bathroom inside of master bedroom, side yard, garage, front yard, and enclosed patio/Atrium in the front area. These are kept off-limits and need to be made inaccessible during operating hours.

LPA did not observe any bodies of water at the property. Should a pool, spa, fountain or pond be installed Licensee is encouraged to contact the Department for regulations.

Licensee states there are no firearms stored in the home. The home was inspected for safety, comfort, cleanliness, ventilation, and telephone service. LPA verified the phone number and email address, which was found to be correct. Fire and safety drills must be performed every 6 months and documented for review by the Department. Licensee states she conducted a fire drill but did not document. LPA provided a sample Emergency drill log. Licensee will be conducting an emergency drill and document this week. No one smokes at the family childcare home. Parent Board was available with all required forms.

In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training EMSA approved, Immunization's (TDAP, MMR, TB, Influenza (or a waiver for the influenza may be in writing), mandated
page 2 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
reporter training and a valid criminal record clearance associated to the facility license. Licensee did have proof of Tdap immunization available.

Detergents, cleaning compounds, medications, and other items, which could pose a danger, were determined to be inaccessible to children in care during this inspection. Knives are kept in a high cabinet with cleaning supplies in the kitchen inaccessible from children. Medications/vitamins were not accessible to children in care. According to Licensee there are no children on medication at this time.

LPA observed the required 2:A-10:B-C fire extinguisher, which was last serviced October 15, 2024. State Fire Marshall standards, state that fire extinguisher shall be purchased or serviced annually. The smoke and carbon monoxide detector were tested and operating properly during the visit. Currently the facility has (1) Dog-Golden Retriever and Australian Shephard mix and is kept in the back yard and inside at times and is free to roam. There are 2 cats, which are indoors and roam free in the house. LPA advised Licensee that pet food needs to be kept in accessible to children in care. LPA observed kitty litter box which was enclosed and away from the children in care located in the bathroom.

Licensee cares for children 24 months and younger, and safe sleep was discussed and LPA advised of PIN 20-24 CCP Safe Sleep and provided Safe Sleep documentation. LPA observed the 15-minute safe sleep log for children under 24 months and discussed Individualized Infant Safe Sleep Plan for children under 12 months. LPA provided the Individualized Infant Safe Sleep plan for a child in care that is under 12 months due to form was not in the file for a child in care.

The licensee has completed training on preventive health & safety practices. Pediatric First Aid and CPR, which includes the EMSA, expired on 3/2023. There are first aid supplies available including surgical scissors, tweezers and emergency manual. Licensee’s Mandated Reporting Training Certificate expired 8/2024. LPA advised that all persons working with children require the AB 1207 Mandated Reporting training which needs to be completed every 2 years. The following link http://www.mandatedreporterca.com/ was provided.

Children and staff files must be maintained and updated as needed and must be available for review by the Department. If children and staff leave the day care all records must be maintained for 3 years after leaving.
page 4 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed that children’s files were complete. LPA advised that the following documents of the LIC 700, LIC 627 and LIC 995A are required, as well as the immunizations. LIC 282 is also needed if liability insurance is not available.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. LPA reviewed clearance list.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, 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: https://www.ada.gov/resources/child-care-centers/. There are no children currently taking medication.
page 3 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SCHREIBER FAMILY DAY CARE
FACILITY NUMBER: 191593040
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiency listed on the following page were observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiencies that is being cited needs to be cleared to protect the children’s health & safety.

Type A - A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form (LIC 9224) during this visit.

A notice of site visit was given and must remain posted for 30 days. An exit interview was conducted, and report was reviewed with the Licensee, Nancy Schreiber.
page 5 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9