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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700600
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:31:15 PM

Document Has Been Signed on 12/07/2023 04:31 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:MIRZAIAN FAMILY CHILD CAREFACILITY NUMBER:
197700600
ADMINISTRATOR:TENI MIRZAIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 221-2137
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
12/07/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Teni Mirzanian. LicenseeTIME COMPLETED:
04:46 PM
NARRATIVE
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On Thursday, December 7, 2023, at 12:38 p.m., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with licensee Teni Mirzaian who guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. During this visit, LPA observed staff #1 present with no background clearance. LPA informed staff #1 cannot be present and must leave. LPA observed 2 infants and 2 preschool children present. LPA observed facility to be within ratio. Operating hours are Monday to Friday from 7:00 a.m. to 6:00 p.m. and care for children ages 0 to 12 years old.

This facility is a two-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, dining room, sunroom, detached garage, front and backyard.

Areas off limits to children include- All second floor, all bedrooms, kitchen, sunroom, garage, kitchen, living room, dining room, laundry room, den/office, and front yard. LPA observed the kitchen and the bottom of the staircase to have an installed safety gates to prevent children access to enter. LPA observed the bedrooms (1st floor) doors closed and locked with a childproof lock. Areas accessible to children include living room, dining room, bathroom located in the hallway and side yard.

At approximately 12:46 p.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone and landline). For ventilation, LPA Rivera observed central AC and the vents located on the ceiling and temperature to be at 74 degrees. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed fireplace to have a screen protector and a cubby in-front. Per licensee, she does not use the fireplace. LPA did not observe infant equipment. During this visit, licensee stated she does not have infants under 18 months in care. LPA observed the cots to be in good condition.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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 12/07/2023 04:31 PM - It Cannot Be Edited


Created By: Mayra Rivera On 12/07/2023 at 02:43 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in have staff #1 present and working with children for more than a month without a criminal records clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee informed staff #1 cannot be present and must leave and cannot return until the facility receives the criminal record clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


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Document Has Been Signed on 12/07/2023 04:31 PM - It Cannot Be Edited


Created By: Mayra Rivera On 12/07/2023 at 02:43 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in not remembering and or documenting emergency dirlls, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Per licensing she will conduct and emergency drill and document drill before the 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.
SUPERVISOR'S NAME:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


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Document Has Been Signed on 12/07/2023 04:31 PM - It Cannot Be Edited


Created By: Mayra Rivera On 12/07/2023 at 02:43 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and licensee statement, the licensee did not comply with the section cited above in not completing the 15 min sleeping logs for infants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Licensee stated will begin documenting the 15 min sleep logs for children 0-2 by due date and keep them in their file.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and licensee statement, the licensee did not comply with the section cited above in not completing LIC 9040 Child Care Facility Roster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Licensee stated will complete LIC 9040 Child Care Facility Roster and will keep document for 3 years.
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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
NARRATIVE
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LPA Rivera observed cleaning compounds items, stored in the garage and underneath the kitchen sink, and observed a childproof lock in place, making it inaccessible for children to open. LPA observed the knives and sharp objects stored inside the top cabinet (above the refrigerator) making it inaccessible for children to reach. For water drinking, licensee stated she provides filtered water and children have their own sippy cups. The licensee stated she provides the 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.

At approximately 1:00 p,m., LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the restroom to be in good condition. LPA reminded licensee and 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 were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has one dog, and no poisons, no bodies of water, no firearms, and no weapons. LPA observed one dog and did not observe poisons, firearms, weapons, nor bodies of water. The license 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 must be stored separately.



At approximately 1:14 p.m. LPA Rivera observed the required 2A10BC fire extinguisher located in the kitchen and the valve on the green area indicating fully charged and serviced on 5/15/22. LPA informed the fire extinguisher must be serviced annually or purchase a new one and show proof of receipt within the year. LPA observed a dual carbon monoxide detector and smoke alarm located in the dining room. LPA tested the dual carbon monoxide/smoke alarm. LPA Rivera heard the sound and is operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA did not observe an emergency drill log. Licensee was not able to provide proof.

At approximately 1:33 p.m., LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be divided in two areas and fenced to separate the yard and gated with a lock. The back is where the dog is located, and the side yard is
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
NARRATIVE
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where children utilize for play. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate. For outdoor water drinking, children bring out their water bottles.

LPA Rivera observed licensee Teni Mirzaian American Heart Association Pediatric First Aid/CPR certification dated 5/21/22 and Health and Safety certification dated 7/10/2012, and licensee has proof of immunization against Pertussis, MMR, and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter (AB 1207) training dated 4/3/2022. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA observed the postings License, LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, and LIC 999 Facility sketch. LPA did not review children’s roster or the 15 min sleep log for the children under 2 years. Licensee stated she was not aware about the roster and the 15 min sleep logs. LPA reviewed children files.

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

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.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
NARRATIVE
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3. In the absence of the licensee 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), AB 1207 Child Abuse Mandated Reporter Certificate.

4. 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.
5. 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

6. 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.

7. 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.

8. 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). Mandated reporter requirements were reviewed and explained.

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

10. Smoking is prohibited in the family childcare home.



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

12. 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.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
NARRATIVE
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13. 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.

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

15. 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).

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

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

18. No baby bouncers, 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.

Licensee Teni Mirzaian 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.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
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LPA discussed the safe sleep regulations with licensee Teni Mirzaian 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 of the importance of Teni Mirzaian 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.

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 Teni Mirzaian 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.

The licensee Teni Mirzaian, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiencies listed on the following page were observed by the LPA Rivera and are being cited in accordance with California Code of Regulations Title 22 and a civil penalty has been issued.



One type A deficiency is being issued today for regulation:
102370(d)- (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MIRZAIAN FAMILY CHILD CARE
FACILITY NUMBER: 197700600
VISIT DATE: 12/07/2023
NARRATIVE
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Three Type B deficiencies are being issued today for regulations:
102417(g)(9)(A)1- (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.
102425(j)(2)- The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document.
102417(g)(8)- (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

Please see attached LIC 809-D for citation deficiencies that are being cited need to be cleared to protect the children’s health & safety. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

During this visit, LPA Rivera provided the Live Scan application for Staff #1,15 min safe sleep log, emergency drill log and LIC 9040 Child Care Facility Roster. LPA explained each form. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the licensee Teni Mirzaian.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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