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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 196216501
Report Date: 10/29/2025
Date Signed: 10/29/2025 02:53:16 PM

Document Has Been Signed on 10/29/2025 02:53 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:WALAWEDURAGE FAMILY CHILD CAREFACILITY NUMBER:
196216501
ADMINISTRATOR/
DIRECTOR:		NAYANI WALAWEDURAGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 451-3382
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
10/29/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Nayani WalTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On October 29, 2025 at 10:20 AM, Licensing Program Analyst (LPA) Brian Fung conducted an unannounced Required- 3 Year inspection. LPA met with licensee Nayani Walawedurage and advised the purpose of the inspection. Licensee provided LPA a tour of the home inside and out. There were nine children in care at the time of the inspection and 2 adults in the home, licensee and husband/assistant.

LPA observed required Licensing required documents posted prominently at the entrance. Fire and earthquake drills are being documented every six months. Last drill was conducted on 8/20/2025. Fire extinguisher 3A40BC mounted on the wall inside in the kitchen. Licensee discussed that they last purchased it at the store Costco, but no receipt was found. A technical violation was cited and licensee will need to have it serviced or purchase a new fire extinguisher with receipt saved and submit picture proof to LPA. Fire and carbon monoxide detectors were located at 10:35 AM. Due to two infants sleeping at the time, the detectors were not tested and licensee confirms the working conditions of the combination detectors.

Children in care have access to two living rooms rooms (one used for indoor play and one used for sleep), one restroom, kitchen, and back yard. Fireplace inside the living room is screened to prevent access by children. Kitchen cabinets were locked and knives are being kept in a locked cabinet near the sink. Children have access to toys that are age-appropriate inside and outside of the home. Back yard play area is enclosed and has plenty of bicycles, scooters, and activities. There are no ammunition and firearms located on the premise. There are no bodies of water present at the time of inspection. During the tour, LPA did not observe any hazards/toxins items accessible to children in care.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501
VISIT DATE: 10/29/2025
NARRATIVE
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LPA reviewed four out of four children files. All children files were current. Licensee and assistant CPR/first aid are expired on 10/15/2025. Licensee will make an appointment to take CPR and First aid with assistant to renew certification and notify LPA when they will take the course and will provide picture proof of certification once course is complete. A type B deficiency was cited for expired CPR and first aid certificate. Licensee was reminded a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter certification AB1207 every two years at www.mandatedreporterca.com Licensee’s mandated reporter certification is valid through 2/28/2026. Assistant's mandated reporter certification is missing. Licensee and assistant were notified that the assistant will need to complete the mandated reporter training and submit proof of certificate to LPA once complete before continuing to care for children. A type B deficiency was cited for missing mandated reporter training. During the assistant's record review, the assistant is missing immunization for Tdap. The assistant discussed that the shot was not available in his home country, Sri Lanka, and did not receive the shot. The licensee and assistant will make an appointment with the doctor to receive that immunization. A Type B deficiency was cited for not having all required immunizations.

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 Child Care 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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501
VISIT DATE: 10/29/2025
NARRATIVE
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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. During the inspection, a baby walker was found in the living room where children plays indoor. Licensee was reminded that baby walkers are not to be used in a family child care home. Licensee was seen removing the baby walker from the home. A type B deficiency was cited.

Loose items/ toy was found with an infant sleeping in a crib with a gray scarf around the infants neck. The toy is a stuffed animal with a body blanket towel. The infant was seen hugging it while sleeping. Another infant was seen sleeping wearing a purple sleep sack. Children under 24 months did not have records of 15 minute sleep checks. Licensee discussed that she does not document the 15 minute sleep checks. 2 type A deficiency was cited for infant safe sleep and 1 Type A deficiency was cited for having no record or documentation of 15 minute infant sleep checks.

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/.

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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501
VISIT DATE: 10/29/2025
NARRATIVE
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During the exit interview, the LICENSEE Nayani Walawedurage, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There were 4 type B deficiencies, 3 type A deficiences, and 1 technical violation cited during today’s inspection.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. A notice of Type A violation must also be posted for 30 days and acknowledgement form must be signed by all current and future parents for 1 year.

Exit interview conducted and report was reviewed with the licensee Nayani Walawedurage.

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Fung
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/29/2025 02:53 PM - It Cannot Be Edited


Created By: Brian Fung On 10/29/2025 at 02:03 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out two infants have a stuffed animal with small towel blanket was found next to infant sleeping. On another infant under 12 months of age, the infant was sleep with a purple sleep sack worn onwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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The licensee will remove the toy from the crib and remove the sleep sack. LPA observed licensee remove the sleep sack from infant that woke up. LPA observed licensee remove the toy that was sleeping with the infant.
Type A
Section Cited
CCR
102425(g)
Infant Safe Sleep
An infant’s head shall not be covered while sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one out of two infant was seen wearing a gray scarf on and attached around infant's neck while sleeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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LIcensee immediately removed the gray scarf from the infant sleeping. LPA observed licensee remove the gray scarf around the infants neck.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 02:53 PM - It Cannot Be Edited


Created By: Brian Fung On 10/29/2025 at 02:03 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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 four out of four counts. The licensee has no records or written report of the 15 minute check for infant safe sleep.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee will begin documenting the 15 minute check for all infants in care. LPA discussed and observed licensee and assistant conducted the 15 minute infant sleep checks.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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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.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 02:53 PM - It Cannot Be Edited


Created By: Brian Fung On 10/29/2025 at 02:03 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

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 one count out of one count. A baby walker was found in the living room play area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee was seen removing the baby walker out of the children's play room. LPA observed licensee remove the baby walker. Licensee confirms with LPA that she will throw the baby walker away.
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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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one count out of 2 counts. Licensee husband, who is also an assistant, has not shown proof of mandated reporter. Licensee says that it is expired and was never renewed and was done over 2 years ago.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Licensee and assistant confirms that they will take the mandated reporter training tonight and submit picture proof of the completed mandated reporter training to LPA by the POC due date of 10/30/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 02:53 PM - It Cannot Be Edited


Created By: Brian Fung On 10/29/2025 at 02:03 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: WALAWEDURAGE FAMILY CHILD CARE
FACILITY NUMBER: 196216501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interview, and record review, the licensee did not comply with the section cited above in 2 counts out of 2 countst. Licensee and husband/assistant CPR and first aid certificaiton are expired on October 15th, 2025. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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3
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Both licensee and assistant will take the pediatric CPR and First aid course and submit picture proof to LPA regarding the completion of the CPR and first aid course.
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 observation, interview, and record review, the licensee did not comply with the section cited above in one count out of two counts. Licensee husband/assistant records does not have immunization for TDap. Husband discussed that the shot was was available in India when he received his immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2025
Plan of Correction
1
2
3
4
Licensee and assistant will go together to the doctors to receive the Tdap immunization. Licensee will provide LPA of picture proof of completed immunization.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Brian Fung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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