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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 05/26/2021
Date Signed: 05/28/2021 12:34:43 AM

Document Has Been Signed on 05/28/2021 12:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR:BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 4DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Farah BangashTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Required 1year/Infection Control Annual inspection. Upon arriving at the facility at 2:30 pm, LPA observed that the licensee did not have the COVID 19 required signs posted on the front door.

LPA was allowed entrance to the facility by a resident, the administrator and staff were on the 2nd floor of the property which is not part of the licensed facility. Upon entering the facility, LPA signed in and the Administrator took LPA’s temperature. Administrator requested for LPA to compete the sign in and document temperature. LPA also observed that other individuals who visited the facility did not records their temperature. The administrator asked the LPA to wait for several minutes while she located the thermometer.

The Administrator stated there are four residents at the facility. One of the 4 resident was later identified as a tenant residing in a resident room. Administrator also confirmed all residents and staff have received the COVID-19 vaccine.

LPA conducted a tour of the facility with the administrator at 2:40 pm to 3:15 pm which revealed the following. with the administrator.

  • Licensee does not have all the required COVID-postings throughout the facility.
  • Routine symptom screening (+/- temperature and symptom check) has not been initiated at entry for all staff, residents, and visitors. The licensee and staff only do temperature checks.
  • Facility does not document daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility.
  • Licensee does not have procedures for when to test staff, and residents to monitor the spread of the virus and mitigate outbreaks. Per administrator they do not do surveillance testing.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/26/2021 at 04:39 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring Routine symptom screening (+/- temperature and symptom check) has been initiated at entry for all staff, residents, and visitors. 2) Not documenting daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/28/2021
Plan of Correction
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Administrator will submit a written statement that she will review her mitigation plan, provide training to ensure all proper symptom screening will be initiated at entry for all staff, residents and visitors. Administrator will also ensure to document the daily symptom and temperature checks.
Type B
Section Cited
CCR
87464(f)(1)
Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not providing all staff who are working with COVID-19 positive residents with fit testing for N95 respirators which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Administrator will provide an updated LIC 500 and verification of N95 respiratory mask fit testing for all staff. Administrator will also schedule surveillance testing for all staff as indicated in their mitigation plan. Administrator will submit the name of the company who will be doing the testing and the copy of the testing schedule for the next month.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/26/2021 at 04:39 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring that Facility has an adequate 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) and a list including items on hand or indicating where such items will be acquired and when
POC Due Date: 06/04/2021
Plan of Correction
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Licensee/Administrator will purchase additional PPE supplies and create a list as indicated above, licensee will also indicate where the PPE supplies will be stored in the facility.
Type B
Section Cited
HSC
1569.267
Notice of rights; signage; non-English speakers’ notice; staff training. (b) Licensees shall prominently post, in areas accessible to the residents and their representatives, a copy of the residents’ rights. Residents rights were not posted during annual visit. (Other required posting were also not observed)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made the licensee did not comply with the section cited above by not having resiednts rights and all other required postings posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Licensee/Administrator will review the health and safety code and post all required postings at the facility. Once completed administrator will submit a written statement with a list of postings that can be found at the facility including but not limited to residents rights, personal rights, Resident council rights, family council rights, complaints poster and LTCO poster
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 05/26/2021
NARRATIVE
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  • Licensee has not provided all staff who are or will be working with COVID-19 positive residents with fit testing for N95 respirators.
  • Licensee has not conducted staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control.
  • Licensee does not have an adequate 30 day supply of PPE
  • Licensee does not have other Department required postings such as the LTCO Poster, Complaint Poster, Emergency Disaster Plan, Personal Rights, Emergency phone number
  • Licensee does not have records for daily resident and staff temperature and symptom checks.


KITCHEN: While touring the Kitchen LPA observed it was clean and sanitary. Licensee has sufficient food supply. LPA did not observe hand washing signs posted in the kitchen.

RESIDENT ROOMS: While conducting a tour of the residents rooms LPA observed the following. The facility has a total of 5 bedrooms and 3 bathrooms for resident use, however LPA observed total of 7 beds in the 5 rooms. Per administrator room # 1 is being used by staff and room # 4 is being utilized by a tenant. According to the pre-licensing report the facility is fire cleared for 5 non-ambulatory and 1 bedridden. During the pre-licensing visit the department was informed that licensee with have 24 hour awake staff and all the rooms were designated for residents. While touring the room LPA Observed that closet in room # 5 was being used as storage for the licensee. Licensee is also storing the facility PPE supplies in an attic accessible only from room # 5. When LPA entered room 5 a female resident was observed sitting on the couch. Administrator told LPA that the resident was residing in that room, however LPA observed Men's clothing and other items in the room, when questioned further administrator stated that the resident does not reside in the room. LPA also observed the resident exit from the backdoor. Administrator apologized to the LPA for being untruthful.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid mat. Upon initial inspection LPA did not observe soap and paper towels in one of the bathrooms. Administrator requested for staff to immediately place soap and paper towels in the bathroom.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 05/26/2021
NARRATIVE
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OUTDOOR SPACE: While touring the backyard LPA observed that the licensee does not have a covered outdoor area for resident use. Licensee also built and ADU behind the house which is not fenced off. According to the administrator the ADU is being rented to 3 different families. LPA observed that the ADU unit has 3 separate doors for entrance. None of the individuals living in the ADU have received criminal record clearance. Administrator has agreed to submit rental agreements for review and to discuss with management if zero tolerance citation will be issued. LPA also observed that there is a gate behind the property that has been designated as an emergency exit however the gate had a key lock that only the ADU tenants have keys to. At 3:20 pm LPA spoke with LAFD inspector and confirmed that a gate which is designated to provide access to LAFD cannot be locked.

At 3:30 pm LPA conducted review of residents records and observed that following

  • Admission agreement for all 3 residents were not SB781 compliant.
  • Physicians report for incomplete for resident 1 (R1) and mission for resident 3 (R3)
  • Licensee is currently retaining a resident who has a diagnosis of Major Neurocognitive disorder without an approved plan of operation.
  • Licensee is not keeping a centrally stored medication and destruction log for 3 out of 3 residents.
  • Licensee does not have PRN authorization logs for residents.

Licensee will submit the following to LPA by 5/29/2021.
  • Liability Insurance
  • Rental Agreements for tenants living in the ADU

Due to computer issues LPA was unable to issue the report and citation on the day of the visit, however the deficiencies and concerns were discussed with the administrator approximately 4:30 to 5:00 . Report was emailed to administrator for signatures on. 5/27/2021.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/27/2021 at 12:47 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring staff have received training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Licensee, Administrator and all staff will receive the required training from an individual trained in inflection control. Verification of staff training will need to be submitted as POC.
Type B
Section Cited
CCR
87465(f)(2)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not having the required emergency agency contact information posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2021
Plan of Correction
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Licensee/administrator will post the required information and submit a photo of the posted information as POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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Page: 7 of 14
Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/27/2021 at 04:26 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with administrator and record review, the licensee did not comply with the section cited above by not keeping/updating centrally stored medication and destruction log for 3 out of 3 resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Administrator will create/update centrally stored medication and destruction log for all residents. Copies of the completed logs and a written statement that the form will be updated regularly will be submitted as POC.
Type A
Section Cited
CCR
87705(b)
In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia,

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on facility application review and pre-licensing report review the licensee did not comply with the section cited above admitting and retaiing a resident diagnosed with Dementia prior to obtaining an approved dementia plan of operation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2021
Plan of Correction
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Licensee/administrator will submit a dementia plan of operation to case LPA for review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/28/2021 at 12:07 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.683
In review of resident's admission agreements it was observed that the facility does not have addendum to the eviction procedure in compliance with SB 781

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not inlcuding required addendums to the admission agreements for 3 out of 3 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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The administrator will read Health and Safety Code 1569.683 and SB 781 and use addendum to eviction procedures. This addendum has to be signed by residents or responsible person and kept in resident's file and copy should be given to residents. A copy of addendum shall be sent to case LPA for review.
Type B
Section Cited
CCR
87465(b)(c)(d)
Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 3 out of 3 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Licensee/Administrator will contact residents Physicians to obtain PRN authorization letters for all residents who they provide medication assistance to. Copies of the PRN authorization letters will need to be submitted as POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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Page: 13 of 14
Document Has Been Signed on 05/28/2021 12:34 AM - It Cannot Be Edited


Created By: Yelena Avetisyan On 05/28/2021 at 12:19 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(a)
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review and interview with the administrator the licensee did not comply with the section cited above by not obtaining a medical assessment for 1 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2021
Plan of Correction
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Licensee/Administrator will obtain medical assessment for Resident 3 (R3). Copy of the assessment will need to be submitted as POC.
Type A
Section Cited
CCR
87465(b)(1)
The medical assessment, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not obtaining a TB for 1 out of 3 residents upon admission to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2021
Plan of Correction
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Licensee/administrator will obtain medical assessment with TB test for Resident 3 (R3). Copy of the Medical Assessment with TB test will need to be submitted as POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


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