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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191607308
Report Date: 05/20/2025
Date Signed: 05/21/2025 08:45:31 AM

Document Has Been Signed on 05/21/2025 08:45 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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MERCADO FAMILY DAY CAREFACILITY NUMBER:
191607308
ADMINISTRATOR/
DIRECTOR:		MERCADO, MARILYN S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 387-5918
CITY:VENICESTATE: CAZIP CODE:
90291
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
05/20/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Julia MercadoTIME VISIT/
INSPECTION COMPLETED:
02:34 PM
NARRATIVE
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On 05/20/2025, Licensing Program Analyst (LPA) Ranita Richmond and Chartrice Johnson conducted an unannounced visit to the above-named Home to conduct the 3 year Required Inspection. LPA was greeted by Licensee Julia Mercado. Assistant S. Mercado was present during the visit.LPA Richmond observed 5 children in care, being supervised and cared for appropriately by licensee and one fingerprint cleared assistant. Hours of operation are Monday through Friday and is open 7:30 a.m. – 5:00 p.m. (time on application is 7:30a- 6:00p, this time change occurred 5 years ago). Licensee does not provide overnight and/or weekend care.

LPA toured the living room, bedroom #1, bathroom #1, and outside for a Health and Safety inspection. LPA was unable to tour the entirety of the home due to licensee refusal. LPA advised licensee that per the facility sketch, LPA unable to identify which rooms were on limits and or off limits. Licensee advised that living room, bedroom #1, bathroom #1, and outside are on limits areas only. The home has heating and ventilation for safety and comfort.

LPA Richmond confirmed with licensee that the home is a single story, single-family home that consists of: Living room, Kitchen, four bedrooms, two bathrooms, detached garage, and gated back yard. LPA provided licensee with LIC 999A to update facility due to no labels of on/off limits areas. LPA provided licensee with LIC 279 to update changes in adults in the home, days and hours of operation, mailing address, and directions to the home.

Per licensee, The OFF LIMITS AREAS are as follows: Detached Garage, kitchen, bedrooms #2, #3, & #4, and bathroom #2 all of which are made inaccessible to children in care by child safety gates, closed and/or locked doors, and visual supervision.

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NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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Document Has Been Signed on 05/21/2025 08:45 AM - It Cannot Be Edited


Created By: Ranita Richmond On 05/20/2025 at 12:58 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 hygiene items in the open tub area and cleaning compounds in the open cabinet in the bathroom with step stool 3 feet away which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee will remove hygiene and cleaning items to make inaccessible or place a lock on tub/ shower door and cabinets to make items inaccessible to children in care.
Type B
Section Cited
CCR
102417(g)(4)(A)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

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 razors in the open tub area and raid in the open cabinet area with foot stool 3 feet away which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee will place raid and razors in a locked area, inaccessible to children in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2025 08:45 AM - It Cannot Be Edited


Created By: Ranita Richmond On 05/20/2025 at 12:58 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above blankets placed loosely inside of 2 of 3 cribs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee will remove all loose items from cribs immediately and store where inaccessible to children in care.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

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 blankets hanging over the side of 1 of 3 and bumper pads in 1 of 3 cribs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee will remove hanging items from the sides of the cribs immediately and place them where they are inaccesible to children in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2025 08:45 AM - It Cannot Be Edited


Created By: Ranita Richmond On 05/20/2025 at 01:37 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(d)(3)(A)

(d)The provider shall place infants up to 12 months of age on their backs for sleeping. (3) An infant with an individual infant sleeping Plan (LIC 9227) that has scetion c of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep....Upon the provider's observation that the infant is capable of rolling from their back to their stomach and stomach to their back....signature.....no later than the next business day following observation.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 of 4 files were missing provider's signature in section D of LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee will sign section D of LIC 9227, provide the Department with copy via email, and place in children's file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maureen Neal
NAME OF LICENSING PROGRAM MANAGER:
Ranita Richmond
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308
VISIT DATE: 05/20/2025
NARRATIVE
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Per licensee, The ON LIMIT AREAS are as follows: Bedroom #1 (napping room), living room(main daycare area/eating/isolation room), bathroom #1, and gated back yard.

Parents and children enter the home through the front door. Which places you inside of the entry way. Walking straight ahead is the living room, inside the living room to the left is a sliding glass door that leads to the gated back yard. Inside the living room to the right is two entry ways, one on the right which leads to bedroom #1. The entry way on the left leads to bathroom #1.

Licensee is aware that the children must nap and have meals in the home. Licensee provides breakfast and appropriate beverages.

LPA Richmond observed a fully charged 3A:40B:C Fire Extinguisher in the living room. Fire extinguisher last serviced in January 2025. LPAs observed working carbon monoxide/ smoke detector dual in the hallway over bedroom #1.

There are no firearms or ammunition on the premises. There are no pools, ponds, or other bodies of water on the premises.

LPA Richmond observed age-appropriate toys, books, and furnishings.

LPAs reviewed fire drill log and observed last fire/disaster drill completed May 2025.

At approximately 10:10am LPAs observed two infant children asleep in cribs, sleeping on their stomachs. Inside 2 of the 3 cribs, loose articles were placed inside the cribs. Type B citation cited. See LIC 809D. In 1 of the 3 cribs loose objects are hanging over the side of the cribs. Type B citation cited. See LIC 809D.

In bathroom #1, LPA observed health and hygiene items in the bathtub area (including shampoos, conditioners, and other hair care supplies) and cleaning supplies in cabinet in the bathroom. Type B citation cited. See LIC 809D. In bathroom #1 LPAs observed Raid in an unlocked bathroom cabinet and razors in the open tub area with foot stool 3 feet away. Type B citation cited. See LIC 809D

LPAs reviewed 5 children’s files. Children’s files are missing providers’ signatures on LIC 9227 for C1, C2, C3, and C4. Type B citation cited. See LIC 809D. LPAs advised licensee to complete the LIC 9227, section D. LPA advised that all infants enrolled in family childcare home who were enrolled under the age of 12 months must sleep on their back until section D is completed by provider. Then 24 hours after completion infants are allowed to remain in position other than back if they roll into the position.

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NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308
VISIT DATE: 05/20/2025
NARRATIVE
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Licensee is in compliance with immunizations requirements for childcare providers. LPA Richmond observed the licensee to have current and updated CPR/First Aid completed 03/22/25, and mandated reporter training completed 05/19/25. LPA advised licensee that flu declination must be completed yearly between August and December, signed, dated, and placed in file for the Department review.

LPA discussed infant sleep chart with licensee. LPA advised licensee that chart must include the infant full name, date of birth, date, initial, time, position of sleep, comments, and waiver if applicable.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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) are not currently being provided.



Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA Richmond reminded Licensee of the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

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

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&R) throughout California.

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NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308
VISIT DATE: 05/20/2025
NARRATIVE
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LPA provided applicant with the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA Richmond gave applicant a packet of all required forms, and posters and reviewed following forms:

CHILDREN'S RECORDS REQUIREMENTS:

· LIC 700 Identification and Emergency Information


· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· LIC 9927 Individual Infant Sleeping Plan
· LIC 995A Notification of Parent’s Rights
· LIC 613A Personal Rights
· Immunization Record

FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Property Owner/Landlord Consent Form
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – must be renewed every two (2) years.

FORMS TO BE POSTED


· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
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NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MERCADO FAMILY DAY CARE
FACILITY NUMBER: 191607308
VISIT DATE: 05/20/2025
NARRATIVE
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In addition, LPA Richmond informed applicant of the following:

o There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.
o Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
o Saucer chairs, bouncers, walkers, or any similar items are prohibited.
o All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
o LPA provided and advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

An exit interview was conducted, a copy of this report was read and provided to Licensee Julia Mercado.

Five (5) Type B Citations issued during this visit per Title 22 Regulations and Health and Safety Codes. See LIC 809D.

Notice of Site Visit was provided and required to be posted for 30 days.

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NAME OF LICENSING PROGRAM MANAGER: Maureen Neal
NAME OF LICENSING PROGRAM ANALYST: Ranita Richmond
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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