197493274-9-16-2025-12-CC-MRIA-DLKRFU-20250916125944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197493274
Report Date: 09/16/2025
Date Signed: 09/16/2025 01:00:28 PM

Document Has Been Signed on 09/16/2025 01:00 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	GUEVARA FAMILY CHILD CARE		FACILITY NUMBER:	197493274
ADMINISTRATOR/ DIRECTOR:	GUEVARA,MARIA & AMILCAR		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 302-0034
CITY:	LAKE VIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	09/16/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:26 AM
MET WITH:	Maria Guevara, Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:07 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On Tuesday, September 16, 2025, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with assistant Ruth who granted access. Licensee was not present upon LPA’s arrival. Licensee arrived in approximately in 20 minutes. LPA observed assistant pediatric first aid /cpr certification dated 1/13/24. Licensee Maria Guevara guided LPA Rivera on a tour of the facility.

Family members residing in the home and staff have been discussed with licensee and are cleared. LPA observed 1 infant and 6 preschool children present. LPA observed the facility to be within ratio. Operating hours are Monday to Friday from 6:00 a.m. to 6:30 p.m. and care for children ages 0 to 13 years old. Annual fee is current.

This facility is a one-story home that consists of 3 bedrooms, 2 bathrooms, kitchen, living room, dining room, and garage.

Areas off limits to children include- All 3 bedrooms, 1 bathroom (master), storage and garage.

Areas accessible to children include- living room, dining room, kitchen, bathroom located in the hallway and backyard.

LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone and landline). For ventilation, LPA Rivera observed central AC/heater, and the vents located on

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 11

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)

Page: 2 of 11

Document Has Been Signed on 09/16/2025 01:00 PM - It Cannot Be Edited

Created By: Mayra Rivera On 09/16/2025 at 11:51 AM

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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee and assistant did not comply with the section cited above in not renewing the child abuse mandated reporting certification, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2025
	Plan of Correction
1 2 3 4	Licensee stated she will look for the updated certificates and if not able to find them, then licensee and assistant will retake the training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Lady King
NAME OF LICENSING PROGRAM MANAGER:

	Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed the fireplace to be barricaded. LPA did not observe a play yard or crib. LPA observed the sleeping mats to be in good condition.

LPA Rivera observed cleaning compounds items, knives and sharp objects stored underneath the kitchen sink, with a childproof lock in place, making it inaccessible for children to open. For water drinking, licensee stated she provides filtered water The licensee stated the facility provides meals and snacks. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies nor on medication.

LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed with no childproof lock. The first drawer does not open easily but LPA Rivera informed to place a child proof lock since there is personal items. LPA observe the bathroom to be in good condition. LPA reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the licensee if there’s any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has two dogs, goats, duck, rabbit and chickens and no poisons and no bodies of water, no firearms, and no weapons. LPA observed dogs, goats, rabbit, and a duck and did not observe poisons, firearms, weapons, nor bodies of water. The licensee was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.

LPA Rivera observed the required 2A10BC fire extinguisher located in the hallway and the valve on the green area indicating fully charged and purchased receipt dated 9/8/24. LPA informed fire extinguisher must be serviced annually or show proof of receipt within the year. LPA observed a dual carbon monoxide detector and smoke alarm located between kitchen and living room. LPA tested the

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 6 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

dual carbon monoxide and smoke alarm. LPA Rivera heard the sound and is operable. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 8/18/25.

LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced, and side gates closed and with a self-latch. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. LPA informed licensee, prior to children coming outside to play, to ensure there’s no animal feces on the play yard.. LPA Rivera observed play structure equipment to be age appropriate and areas around or under high climbing equipment, are cushioned with grass and woodchips and may absorb a fall. LPA observed two BBQ grills and observed them covered. LPA reminded licensee the propane tanks must be stored in the off-limits area. LPA did not observe any children playing outside due to the heat wave.

LPA Rivera observed licensee Maria Emergency Medical Service Authority (EMSA) Pediatric First Aid/ CPR certification dated 1/13/24 and Health and Safety certification dated 12/8/2016 and licensee has proof of immunization against Pertussis, MMR, and Influenza declination. Licensee completed the child abuse mandated Reporter (AB 1207) training dated 12/30/22. LPA informed licensee that the child abuse mandated reporter certificate expired on 12/30/24 and certification must be renewed every two years.

LPA observed the postings: License, Pub 394 Notification of Parents Rights, and also reviewed roster, children and staff files and sleep logs.

The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 7 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

2 Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee 80/20 a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 8 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

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.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 9 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee Maria Guevara 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.

LPA discussed the safe sleep regulations with Maria Guevara and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Maria Guevara of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 Maria Guevara 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.

Licensee Maria Guevara confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations. Health and Safety- 1596.8662(b)(1)- (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider,

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 10 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUEVARA FAMILY CHILD CARE	FACILITY NUMBER: 197493274
	VISIT DATE: 09/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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. Please see attached LIC 809-D for citation. Due date 10/16/25.

A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty Exit interview conducted,report and appeals rights were reviewed with the licensee Maria Guevara.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC809 (FAS) - (06/04)

Page: 11 of 11