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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 09/03/2025
Date Signed: 09/03/2025 03:19:39 PM

Document Has Been Signed on 09/03/2025 03:19 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:VIP SENIOR LIVING LLCFACILITY NUMBER:
197609827
ADMINISTRATOR/
DIRECTOR:		AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:5457 WOODMAN AVETELEPHONE:
(818) 994-4116
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 4DATE:
09/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Jeffrey Alvarez - Licensee
Madeleine Ayllon - Administrator		TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:36AM. The LPA was greeted by Staff, informed them of the reason for the visit, and Staff proceeded to notify the Licensee and Administrator. Licensee Jeffrey Alvarez and Administrator Madeleine Ayllon arrived at 10:56AM. Entrance interview conducted.

Beginning at 9:53AM, the LPA and Staff toured the physical plant areas inside and outside to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Knives were stored inaccessible in a locked drawer near the sink with cleaning supplies stored inaccessible and locked under the sink. The LPA observed the lower drawers to the right of the stove was not on its tracks/hinges and contained an unsecured hammer and butcher knife. The Staff secured the knife and hammer immediately. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable food and did not have a sufficient supply of non-perishables. The Licensee purchased non-perishables during the visit. Non-perishables consisted of five (5) canned tunas located in the cabinet pantry. Interview with Staff and the Licensee revealed the facility did not have emergency food. Food in the refrigerator and freezer were observed to be properly stored and labeled. The LPA observed the lower fridge drawer containing produce was also in disrepair and was sitting on the bottom of the fridge, not on the hinges.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 09/03/2025
NARRATIVE
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COMMON AREAS: At the time of the visit, the facility had two (2) living rooms, a dining room, and a den with furniture observed to be in good condition. Dining room cabinets contained unsecured medications which the Staff stated were old and belonged to prior residents. The Staff discarded of the medications. Required postings were in the entryway hallway and the dining room. The LPA observed water damage on the ceiling, above the dining table. The two (2) ceiling planks were lifting, had water stains, and cracks. The LPA observed emergency water stored near the second living room. The hallway closet contained extra linens, and the closet doors were in disrepair as they were leaning and not aligned with the closet tracks. The Staff stated it has been broken for 2 months. The facility maintained a comfortable temperature throughout the visit.

BEDROOMS/RESTROOMS: There were six (6) total bedrooms: one (1) staff room, one (1) guest room, and four (4) private resident rooms. Bedroom #5 had a direct exit to the outside and was approved for one (1) bedridden resident. The guest room was occupied by a family member of the Licensee who was fingerprint cleared but was not associated with the facility. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom #4 had window blinds that were in disrepair with seven (7) panels broken off. There were four (4) total restrooms in the facility: two (2) staff restrooms, one (1) private resident restroom, and one (1) shared resident restroom in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. The shared resident restroom contained a closet with extra linens and towels. One (1) staff restroom had accessible cleaning supplies, laundry detergent, and insect aerosol sprays. Hot water was tested and measured between 97 degrees F and 138.2 degrees F, which was not in the required range of 105 degrees F and 120 degrees F. The Licensee stated they would lower the water temperature.

OUTDOOR AREA: The surrounding grounds had one (1) shaded patio area equipped with furniture in good condition for residents and visitors to use. There were two (2) manual driveway gates, and two (2) self-latching gates used for emergencies. No bodies of water noted, and exits were free of obstructions.

Report Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 09/03/2025
NARRATIVE
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The rear had laundry machines that were observed to be operational with a nearby garage. The garage contained general storage and had a broken door handle that was inoperable. The LPA and Staff pushed the garage door open to gain access.

RECORDS: Record review began at 11:07AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a TB test result on file. The Administrator contacted their Physician who stated a skin test was not done and would check for X-Ray results. At this time the facility could not provide the LPA the TB results. Four (4) out of four (4) residents’ Pre-Placement Appraisal and Appraisal/Needs and Services Plans were completed but did not have the residents’, or their representative’s, signatures. The Administrator stated they review all documents with the families over the phone, however, did not obtain signatures. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The LPA discussed the documentation of staff training to include the training hours, per regulation. The Administrator understood.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 07/15/2025. Smoke and carbon monoxide detectors were tested at 11:06AM and were operational at the time of the visit. Two (2) fire extinguishers were observed throughout the facility and were last serviced on 08/05/2025.

Report Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 09/03/2025
NARRATIVE
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MEDICATIONS: Medication review began at 12:17PM. Medications were centrally stored and kept inaccessible in the hallway cabinet located between the staff room and staff restroom. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. R1 had Acetaminophen 650MG filled on 12/26/2024 that was not documented. Resident #2 (R2) had two (2) Quetiapine Fumarate 25MG filled on 08/01/2025 and 08/25/2025, and two (2) MAPAP 500MG filled on 07/11/2025 and 08/04/2025 that were not documented. The Administrator stated that Staff must not have documented the medications because it was not yet in use. Additionally, R1 did not have a PRN (as needed) Authorization Letter. R2 had an outdated PRN Authorization Letter that did not reflect the current PRN medications they were taking. The Administrator stated they would contact Hospice to obtain the letters.

Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the appeal rights and report were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 03:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2025 at 02:41 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 restroom sinks did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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The Licensee will adjust the water temperature and send CCLD proof of the water temperature measuring within the required range by the POC due date.
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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Based on observation, the licensee did not comply with the section cited above in the staff restroom had unsecured cleaning supplies and the kitchen drawer had an unsecured butcher knife and hammer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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The Licensee secured the knife and hammer and will secure the cleaning supplies and send proof to CCLD by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 03:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2025 at 02:41 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medications were unsecured in the dining room cabinets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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The Licensee secured or discarded of the medications during the visit. POC Cleared.
Type A
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 the facility did not have emergency food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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The Licensee will purchase emergency food and send CCLD proof by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 03:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2025 at 02:41 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

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 observation and interview, the licensee did not comply with the section cited above in the facility had broken drawers, door handles, closet doors, window blinds, and ceiling water damage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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The Licensee will have their handyman make all the repairs and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility did not have a sufficient supply of non-perishable food which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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The Licensee purchased non-perishables during the visit. POC Cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 03:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2025 at 02:41 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 2 residents' medications were not properly documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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2
3
4
The Licensee will review all medications and update the Centrally Stored Medications and Destruction Record and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 residents did not have PRN Authorization Letters which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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2
3
4
The Licensee will obtain PRN Authorization Letters for all residents and send CCLD proof by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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