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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597634
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:49:53 PM

Document Has Been Signed on 07/18/2024 03:49 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HOPE LUTHERAN PRESCHOOLFACILITY NUMBER:
191597634
ADMINISTRATOR/
DIRECTOR:		HEAD, ELLENFACILITY TYPE:
850
ADDRESS:1041 E. FOOTHILL BLVD.TELEPHONE:
(626) 335-5315
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 20DATE:
07/18/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ellen Head - DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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 Licensing Program Analyst (LPA) Cynthia Reyes conducted an unannounced annual required site Inspection to ensure the health and safety standards as required by the regulations governing child care centers are met for this preschool program. LPA met with Ellen Head - Director, who a copy of the Entrance Checklist for Child Care Centers form (LIC 125) was provided. Facility is located on the Hope Lutheran Church site. The days and hours of operation are Monday to Friday from 630 AM to 6 PM. Licensee email address was verified/obtained during this inspection. The director was advised that the email may be public information.

Director Ellen took LPA on a tour of the school inside and out. Director states parents will enter the facility from the parking lot located on the back or side of the facility. Parents sign in/out is done right outside the classrooms. The parent board is located in the same area and required postings are visible for all to see. Facility has telephone service and phone number to the school was verified. Health checks are conducted in the class rooms.

The ill/isolation area is located in the Directors office and the staff rest room for an ill child to use is located in another room in the directors office. The ill/isolation area will have the child cot brought in for the child to rest if needed. No staff lounge/lunch area. Staff will use the directors office, outside or the small chapel of the church which is located on this campus

LPA was guided through the preschool classrooms (Rainbow P3 age 2/3 and Sunshine P4 age 4/5). The following was observed during this inspection. LPA took staff names and position and children census. Preschool class rooms consist of 2 rooms. LPA observed 3 teachers with 20 preschoolers in 1 class room. The other classroom is not in full use due to low enrollment for the summer. both rooms were still inspected.
Teacher child ratios were discussed in accordance with Title 22 Regulations and observed. LPA observed the licensed facility is within the conditions, limitations, and capacity specified on the license.
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634
VISIT DATE: 07/18/2024
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LPA discussed Responsibility for Providing Care and Supervision that children should be under direct supervision and observation, including visual supervision, of a teacher at all times.

LPA observed, age appropriate fixtures, furniture, equipment and supplies and all was inspected for age appropriateness and is in good repair. LPA observe and inspected sleeping equipment (cots) are age appropriate and in good repair. Toys and play equipment were also observed to be age appropriate clean and safe. All surfaces and materials accessible to children, including toys, are toxic free. LPA observed the facility has central heat and air, overhead lights as well as natural light. Individual storage space was observed to be available for each child and cleanliness was observed in the room.

LPA observed the children's bathrooms and all are in good condition, water temperature, paper towels, toilet paper, and all were inspected for safety, sanitation and operable. Child care centers shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well being of children, employees and visitors. Preschoolers have a bathroom with 4 sinks and 4 toilets. A wall changing table is next to a sink.

The facility provides AM/PM snack and lunch is brought by the child or a hot lunch can be purchased by an outside vendor cater Tots. Menus were observed posted. In the directors office a refrigerator and small kitchen/preparation area was observed. Containers used to discard food have tight fitting lids. Facility provides each child's linen for the week and the parents will take home to wash at the end of the week or as needed. Facility has extra linen and food available if needed. The school provides water for the children to fill their own water bottles if needed and drink freely. Licensee will take measures to keep the facility free of flies, other insects and rodents.

Carbon monoxide detectors and smoke detectors are present and are in operable condition in the class rooms. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. The fire extinguisher type 2A-10BC (Service date 12/12/2023) must be serviced annually or as often as necessary. Fire and earthquake drills must be conducted every 3 months and documented. Last drills were conducted on 05/21/2024. Hazardous items including disinfectants, poisonous, cleaning solutions and any other items that could pose a danger to children were observed to be stored inaccessible to children.
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634
VISIT DATE: 07/18/2024
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Licensing staff was then guided to the outdoor play area. The yard is self contained by a gate around the day care class rooms. Children will use their own water cups while outdoors. LPA observed age appropriate outdoor toys, play equipment and materials to be clean, safe and in good repair, as well as adequate shade available by use of covers over the craft and eating tables. All areas around play equipment and slides are cushioned with material to absorb a fall. LPA advised the licensee that the children need to be within the direct care and supervision, including visual observation and supervision of the teacher(s) at all times. No bodies of water were observed on the premise.

The facility has no transportation policy. Director states that any lifesaving medication will be stored in a locked area inaccessible to children in care. There is a fully equipped first aid kit available in each room. First aid supplies were observed to have all the required items including a thermometer

Criminal Records clearance: Director was reminded that all adults 18 and over 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 Child Care center. 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.



Lead Testing: Assembly Bill (AB) 2370, Chapter 676, statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water used for drinking and food preparation) for lead contamination before January 1, 2023 and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21,1-CCP). LPA verified that the lead testing was completed on 12/13/2022 with "0" Exceedance in accordance to the Written Directives outlined in PIN 21-21,1-CCP. LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and water Testing Information.

This facility provides incidental medical services- IMS. LPA reviewed where medication and equipment and supplies are located for "0" children who have IMS and review of children's file and administrative records.
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634
VISIT DATE: 07/18/2024
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For IMS information see PIN 22-02- CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/resources/child-care-centers/.

Children’s Records were reviewed for completeness. Inspection of required forms were made and documented on the LIC 857. LPA reviewed Staff records, which are documented on the LIC 859. Staff present will be verified too have proof against TB, measles, pertussis, and influenza, as well as current Mandated reporter. LPA observed during staff file review, that there is at least one person present on this date and at all times, with Pediatric CPR & First Aid. Children's roster & Staff Personnel report was reviewed for completeness.



MyChildCarePlan.org – Licensee, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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 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/process.

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634
VISIT DATE: 07/18/2024
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At this time, the licensee is not in compliance with California Title 22 Regulations. Therefore, There were deficiency cited during today's Inspection in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1. See 809D pages for citations. Consultation was conducted on this date.

LPA Reyes informed Administrator Ellen Head that this report dated 07/18/2023 documents 2 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Director was also informed, that she needs to provide a copy of this licensing report dated 07/18/2024, that documents 2 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification

Exit interview conducted and report was reviewed and consultation was given to Ellen Head - Directorr.


A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/18/2024 03:49 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 07/18/2024 at 02:17 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: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101216.1(c)(1)
Teacher Qualifications and Duties
(c) To be a fully qualified teacher, a teacher shall have one of the following: (1) Twelve postsecondary semester or equivalent quarter units in early childhood education or child development completed, with passing grades, at an accredited or approved college or university; and at least six months of work experience in a licensed child care center or comparable group child care program.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview and record review, the licensee did not comply with the section cited above in 1 count out of 1 total count persons identifiers which poses an immediate health, safety or personal rights risk to persons in care. STAFF #2 IS BEING USED AS A PRESCHOOL TEACHER AND DOES NOT HAVE THE UNITS AS A FULLY QUALIFIED TEACHER
POC Due Date: 07/18/2024
Plan of Correction
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Director Head will be promoting staff #3 to a teacher position and will submit all required documents for her through email.
Type A
Section Cited
CCR
101216.2(e)
Teacher Aide Qualifications and Duties
(e) An aide shall work only under the direct supervision of a teacher.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview and record review, the licensee did not comply with the section cited above in 1 count out of 1 total count persons identifiers which poses an immediate health, safety or personal rights risk to persons in care.
AIDS WERE OBSERVED AND INTERVIEWED ABOUT BEING ALONE WITH THE CHILDREN IN THE CLASS ROOM AND ON THE PLAY GROUND
POC Due Date: 07/18/2024
Plan of Correction
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Director Head states will write a letter to the department on how she will ensure teacher and aids follow the regulation and job duties for their position. Director will sign and date, email and mail original.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/18/2024 03:49 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 07/18/2024 at 02:17 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: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

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
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2
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4
Based on record review, the licensee did not comply with the section cited above in 1 count out of 5 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. STAFF # 2 IS MISSING A MANDATED REPORTER
POC Due Date: 07/26/2024
Plan of Correction
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Director Head states will have staff #2 complete the training and submit a copy of her certificate by the POC date.
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 3 count out of 5 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. STAFF # 2,3, AND 4 ARE MISSING PROOF OF MMR/TDAP
POC Due Date: 07/26/2024
Plan of Correction
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Director Head states will have staff gather proof of their MMR and TDAP and will submit by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/18/2024 03:49 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 07/18/2024 at 02:17 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: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(f)
Child Care Center Director Qualifications and Duties
(f) When the child care center director is absent from the center, arrangements shall be made for a fully qualified teacher as specified in Section 101216.1(c) to act as substitute. This substitute child care center director shall be aware of center operations, including total enrollment; shall be trained in program operation; and shall be designated as an authorized person to correct operational deficiencies that constitute immediate threats to children's health and safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 count out of 1 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. DIRECTOR DOES NOT HAVE A FULLY QUALIFIED STAFF OR DESIGNATION OF FACILITY RESPONSIBILITY ON FILE
POC Due Date: 07/26/2024
Plan of Correction
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2
3
4
Director states will designate her lead teacher and submit proof by the POC date.
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 count out of 5 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. STAFF #4 DOES NOT HAVE A LIC 503/TB ON FILE
POC Due Date: 07/26/2024
Plan of Correction
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2
3
4
Director states will have staff #4 get her LIC 6503/TB and submit a copy by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/18/2024 03:49 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 07/18/2024 at 02:17 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: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 191597634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

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 2 count out of 6 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. CHILD #3 AND 4 ARE MISSING IMMUNIZATION'S RECORDS
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Director states will gather the children's immunization's and submit proof by the POC date.
Type B
Section Cited
HSC
1596.8595(c)


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 5 count out of 6 total count persons identifiers which poses/posed a potential health, safety or personal rights risk to persons in care. A licensed child care home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of section 1596.893b
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Director states
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:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


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