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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850298
Report Date: 12/23/2025
Date Signed: 12/23/2025 04:33:30 PM

Document Has Been Signed on 12/23/2025 04:33 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAURELGROVE BOARD AND CAREFACILITY NUMBER:
195850298
ADMINISTRATOR/
DIRECTOR:		MARTIROSIAN, HRACHIAFACILITY TYPE:
740
ADDRESS:8221 LAURELGROVE AVETELEPHONE:
(818) 355-2632
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
12/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Dianna KarapetyanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:28 AM. LPA met with facility staff who contacted the facility Administrator Dianna Karapetyan. The Administrator arrived to the facility at 09:43 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:45 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

OUTDOOR SPACE: The facility had one (1) emergency exit gate located in the front yard; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed a locked storage shed which contained tools and extra care supplies. The backyard was observed to contain an appropriately fenced pool that was empty of all water at the time of the visit. One (1) extra refrigerator was observed in the backyard of the facility. At 09:49 AM LPA observed an unsecured hand saw in the back yard near the storage shed. LPA informed the Administrator who immediately secured the item in locked storage.

BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a dual occupancy room and four (4) are single occupancy rooms. LPA and facility Administrator toured all five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and all were functional at the time of the visit. Bedrooms #1 & 2 contain direct exits to the outdoors of the facility. Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2025
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.

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298
VISIT DATE: 12/23/2025
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BATHROOMS: There are four (4) resident bathrooms at the facility and one (1) staff bathroom. Three (3) bathrooms are designated as private resident bathrooms, one (1) bathroom is designated as a shared resident bathroom. All bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 111.9 and 113.7 degrees Fahrenheit, which is within the range required by regulation.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a secured under sink cabinet which contained cleaning chemicals. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and serviced on 01/05/2025.

COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the dining room to be clean and properly furnished at the time of the visit. The living room was observed to contain activities for resident use including a television. The dining area contained a dining table with adequate seating for resident use. LPA observed a locked hallway closet to contain resident medications and facility files. All furniture throughout the facility was observed to be relatively clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 10:37 AM and were functional at the time of the visit. LPA observed an ADU on the property that was not present at the last annual visit. On 05/12/2025 Community Care Licensing Division (CCLD) was notified of proposed construction at the facility. On 05/12/2025 LPA requested documentation pertaining to the proposed construction including an updated facility sketch. LPA reviewed documentation submitted to CCLD by the Administrator and did not observe an updated facility sketch. LPA informed the Administrator that an updated sketch was requested by CCLD but was not received. The Administrator agreed to send an updated facility sketch to CCLD. Additionally, LPA informed the Administrator that due to the layout of the newly constructed ADU tenants of the ADU share common outdoor areas with facility residents. LPA informed the Administrator that because tenants of the ADU have access to the facility, any future tenants in the ADU will be required to obtain finger print clearance and have association to the facility. LPA informed the Administrator that failure to comply could result in the issuance of civil penalties. The Administrator expressed understanding and agreed to comply with the requirements.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298
VISIT DATE: 12/23/2025
NARRATIVE
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RECORD REVIEW: Record review began at 10:50 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. Staff #1 (S1) was observed to be hired on 12/15/2025. During the visit LPA observed S1 to be providing assistance to residents with activities of daily living (ADLs). LPA reviewed S1’s file and did not observe trainings on file. LPA asked the Administrator why trainings were not in S1’s file and the Administrator informed LPA that some trainings had been completed but since S1 was new no documentation had been created. LPA informed the Administrator that staff members shall complete twenty (20) hours of training, including six (6) hours specific to dementia care and four (4) hours specific to postural supports, restricted health conditions, and hospice care, before working independently with residents. The Administrator expressed understanding and agreed to complete the required trainings with S1. Six (6) resident files were reviewed. Resident #1’s (R1) file was observed to contain an admission agreement for a different facility. LPA informed the Administrator who stated that R1 was transferred to this facility but no new admission agreement was created because both facilities are run under the same Operator. LPA informed the Administrator that admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, and the licensee or the licensee’s designated representative no later than seven (7) days following admission. The Administrator expressed understanding and agreed to complete an admission agreement for R1.

MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for three (3) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are to be conducted quarterly the Administrator was unable to provide LPA with documentation that showed the facility’s last emergency disaster drill. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298
VISIT DATE: 12/23/2025
NARRATIVE
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INTERVIEWS: LPA interviewed three (3) residents and two (2) staff members. All three (3) residents interviewed had concerns relating to the variety of food served at the facility. LPA informed the Administrator of the concerns regarding the variety of foods offered for meals. The Administrator agreed to implement a more robust and varied menu for the dinner service at the facility. One (1) staff interview was conducted with the assistance of the facility Administrator acting as a translator. Both staff members interviewed understood their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited. (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2025 04:33 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/23/2025 at 03:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025

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

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above as there was an unsecured hand saw located in the back yard which posed an immediate safety risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Administrator secured the saw at the time of the visit. POC cleared.
Section Cited
Deficient Practice Statement
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3
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


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Document Has Been Signed on 12/23/2025 04:33 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/23/2025 at 03:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

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 as S1 did not have the required 20 hours of trainings logged prior to working directly with residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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3
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Administrator agreed to conduct the required 20 hours of training with S1 and to submit proof of the completed trainings to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


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Document Has Been Signed on 12/23/2025 04:33 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/23/2025 at 03:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(5)
General Food Service Requirements
(b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above as three of three residents interviewed had complaints about the variety of foods served at the facility which poses a potential personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator agreed to develop their plan on how they will ensure adequate food variety for resident meals. Administrator agreed to submit their plan and a log of meals served over a two week period to CCLD no later than POC due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above as one resident did not have a completed admission agreement for this facility in their file which poses personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator agreed to complete the admission agreement for the identified individual and to submit the agreement to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


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Document Has Been Signed on 12/23/2025 04:33 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/23/2025 at 03:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 as the facility did not log the last time a disaster drill was completed which poses a potential safety risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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2
3
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Administrator agreed to conduct and appropriately log a disaster drill. Administrator agreed to submit proof of the completed drill to CCLD no later than POC due date.
Type B
Section Cited
CCR
87208(a)(7)
87208 Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility…Any significant …shall be submitted to the licensing agency for approval…shall contain the following:
(7) Sketches, showing dimensions, of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as in May the licensee notified CCLD of construction changes but did not submit an updated facility sketch to the department which poses a potential safety risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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2
3
4
Administrator agreed to submit an updated facility sketch to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


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