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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012340
Report Date: 09/08/2025
Date Signed: 09/08/2025 02:37:09 PM

Document Has Been Signed on 09/08/2025 02:37 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:OVSEPIAN FAMILY CHILD CAREFACILITY NUMBER:
198012340
ADMINISTRATOR/
DIRECTOR:		OVSEPIAN, TSOVINARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 353-3096
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
09/08/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Tsovinar Ovsepian, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On Monday, September 8, 2025, Licensing Program Analyst (LPA) Evelyn Garcia conducted an unannounced annual inspection and met with licensee, Tsovinar Ovsepian, who guided LPA Garcia on a tour of the facility. Family members residing in the home include Licensee and licensee’s spouse. All have been discussed with licensee and are cleared. During the inspection there were 13 children present and 2 adults providing care and supervision. Operating hours are Monday to Friday from 7:30 am to 5:30 p.m. and care for children ages 3 ½-5 years old. This facility is a single-story home that consists of 3 bedrooms, 3 bathrooms, kitchen, living room, dining room, day care area, and front and backyard fenced. There is a fireplace on premises and an in-ground pool.

Areas off limits to children include- Main home areas including, kitchen, pantry, living room, 2 bedrooms, back yard where the pool is located, bathroom located in hallway.

Areas accessible to children include the back portion of the home where the main daycare space is located, bedroom used as additional room for the day care, front yard fenced. The day care is divided into 2 rooms, the larger room is the main day care area, and bedroom used as a napping and additional day care area. The front yard is utilized by the children for outdoor gross motor play.

LPA Garcia inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Garcia observed central A/C and Heating and vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did observe a fireplace however, it is barricade with metal mesh gate making it inaccessible to the children in care and is in an off-limits area of the home. LPA observed cots for children that are utilized for naptime. Napping takes place in the bedroom of the day care space.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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.

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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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340
VISIT DATE: 09/08/2025
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LPA Garcia observed cleaning compounds stored in the laundry room located in off-limits part of the home. Sharp knives were observed to be stored in a kitchen drawer, also off limits to the children. For water drinking, licensee stated she provides filtered water, and the children use disposable cups. The licensee stated she does not participate in a food program. 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 Garcia entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed. LPA Garcia observed the restroom to be in good condition, clean and operable.

LPA Garcia asked the licensee if there were any pets, poisons, firearms, weapons. The licensee stated there are no pets, no poisons, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, or weapons. 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.



LPA Garcia observed an in-ground pool that is completely surrounded by a mesh fence, which measures 5’, has a pool gate that swings away from the pool and is self-latching. The lock is located within 6’’ from the top of the pool gate. The pool fencing does meet Title 22 regulations; however licensee was not aware of new state regulations that took into effect in 2025. Was issued a type B violation and agreed to purchase the pool alarm, life ring, rescue pole and will make daily inspections/ documentation before children arrive to the daycare.

LPA Garcia observed the required 2A10BC fire extinguisher located in the current napping room and the valve on the green area indicating fully charged. LPA observed dual smoke and carbon monoxide detector located in the hallway. Licensee tested the alarm. LPA Garcia heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room. For ill isolation, licensee stated she utilizes a corner of the day care room until parent’s pick up the child. Last drill conducted 9/25.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340
VISIT DATE: 09/08/2025
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LPA Garcia inspected the play outdoor (front yard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the front yard to be gated with a metal fence measuring over 5’, and gates closed and with a lock. 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 (concrete, artificial turf) is maintained in a safe condition and is free of hazards. There is a large tree that provides shade for the majority of the play space. Climbing equipment is placed over artificial turf that may cushion a fall. For outdoor water drinking, licensee brings out a jug and disposable cups.

LPA Garcia observed Staff #1 licensee Pediatric First Aid/ CPR certification dated 10/23/24 and licensee had proof of immunization against Pertussis, Measles, flu declination and TB. Staff did not have Measles, pertussis although flu declination and TB was on file. Licensee has completed the Child Abuse Mandated Reporter (AB 1207) training dated 9/14/24. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA observed the required postings License, LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, LIC 999 Facility sketch. LPA also, reviewed children roster, children files and staff files. LPA observed the children’s files to be missing vaccine records and LIC 700.

The following was also discussed with the licensee:



1. 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.

2. 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.

3. 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.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340
VISIT DATE: 09/08/2025
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4. 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.

5. 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.



6. 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.

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

8. Smoking is prohibited in the family childcare home.



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

10. 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.

11. 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.



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

13. 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).

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

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340
VISIT DATE: 09/08/2025
NARRATIVE
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15. Dog(s) and/or pets are recommended to be isolated from children in care.

16. 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.

Criminal Record Clearance - Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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

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/.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340
VISIT DATE: 09/08/2025
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

There were 2 Type B violations issued during this visit due to

Corrections needed: 1) Pool alarm 2) Rescue pole 3) Life Ring 4) proof of vaccinations for staff 5) proof of vaccinations for children enrolled 6) Personal Rights Receipt in children's file 7) Consent for emergency medical treatment in children's file

LPA Garcia texted a PDF form which states the requirements for the equipment stated above. In addition, all information can also be found at www.cdss.ca.gov

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Tsovinar Ovsepian.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Evelyn Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2025 02:37 PM - It Cannot Be Edited


Created By: Evelyn Garcia On 09/08/2025 at 01:55 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: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee was not aware of regulation that took into effect in 2025. (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water.(B) A rescue pole with a body hook and a minimum fixed length of 12 feet. (c) Life Ring that is certified by USCG.
POC Due Date: 09/15/2025
Plan of Correction
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Licensee will purchase the items that meet standards and show proof of purchase to LPA Garcia via email.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA Garcia observed that in the inspection prior it was discussed that staff needed to show proof of immunization.
POC Due Date: 09/15/2025
Plan of Correction
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Licensee will submit proof of immuizations or medical exemption for her staff by the above stated 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.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Evelyn Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2025 02:37 PM - It Cannot Be Edited


Created By: Evelyn Garcia On 09/08/2025 at 01:55 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: OVSEPIAN FAMILY CHILD CARE
FACILITY NUMBER: 198012340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review. the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee stated that the child's parents did not want to vaccinate their child and LPA Garcia observed a hand written note from parents in the child's file that states "have refused to vaccinate my son..due to personal and private beliefs..."
POC Due Date: 09/22/2025
Plan of Correction
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Licensee will ask the parents for proof of vaccination or medical exemption so that he can continue to attend the daycare.
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.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Evelyn Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


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