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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016267
Report Date: 09/14/2021
Date Signed: 09/14/2021 02:19:22 PM

Document Has Been Signed on 09/14/2021 02:19 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:VILLAGRAN FAMILY CHILD CAREFACILITY NUMBER:
198016267
ADMINISTRATOR:CELEST VILLAGRANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 610-2584
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Celest Villagran, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rita Ramos conducted an unannounced required 1 year inspection to the above facility on 09/14/2021. LPA arrived at the facility at 8:45:AM and met with Celest Villagran, Licensee who guided analyst on a tour of the facility. LPA provided Licensee with a copy of the LIC 126 Entrance Checklist to help facilitate the inspection. LPA observed that also present during this inspection, was Karen Munoz, Licensee’s Assistant. LPA observed 6 children upon arrival. Per Licensee, operation hours are 7AM to 6PM. There are 10 children that are currently enrolled. A current children’s roster was available for review.

This home is located in a duplex property which is divided into 3 homes. Licensee resides in the back home with their own address number separate from the other 2 residences on this property. Licensee resides on the first story which consists of 1 bedroom, 1 bathroom, kitchen, living room, backyard. The children use the bathroom next to the kitchen and bedroom. LPA observed that there is no fireplace or wall heaters. Per Licensee, children have access to the bedroom, bathroom, living room, and kitchen. The kitchen has a gate that is placed if Licensee is cooking, other than that, the kitchen is accessible. The licensee provides food for children in care.

Individuals who reside in the home were noted and discussed. Per Licensee, they currently have one assistant.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated

Licensee states that there are no firearms stored in the home. ----------Page 1 of 5
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 09/14/2021 02:19 PM - It Cannot Be Edited


Created By: Rita Ramos On 09/14/2021 at 11:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)
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:

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 due to the backyard being under construction and LPA observing sand bags, a metal fencing with protruding metal bars at the bottom, and open accessible garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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Per Licensee, a written explanation as to what occurred and what the future child care plans are will be submitted by POC due date of 09/15/21.
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 due to LPA observing Raid ant and roach killer under the sink in an unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2021
Plan of Correction
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Licensee removed Raid poison during the inspection and will submit a written plan as to how they will store poisons in the future and will submit it by POC due date of 09/15/21.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Rita Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 09/14/2021 02:19 PM - It Cannot Be Edited


Created By: Rita Ramos On 09/14/2021 at 11:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

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 due to LPA observing that an area that is considered off-limits which is the front yard is being used by children in care and has rose bushes accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Per Licensee, Licensee will submit a letter requesting the temporary use of the front yard and will cover the rose bushes and take pictures that will be submitted by POC due date of 09/17/21
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:Trevino Cochran
LICENSING EVALUATOR NAME:Rita Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/14/2021 02:19 PM - It Cannot Be Edited


Created By: Rita Ramos On 09/14/2021 at 11:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

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 observation, interview, and record review the licensee did not comply with the section cited above due to Licensee admitting that the do not have a sleeping log for infants in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2021
Plan of Correction
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Per Licensee, they will create a log and submit a copy by POC due date of 09/28/21.
Type B
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

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 due to not informing the department of the construction taking place int he backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2021
Plan of Correction
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Per Licensee, an incident report will be submitted by POC due date of 09/28/21.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Rita Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 09/14/2021 02:19 PM - It Cannot Be Edited


Created By: Rita Ramos On 09/14/2021 at 11:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 due to not having a file to review for Child #5 and #6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2021
Plan of Correction
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Per Licensee, they will make sure to have the forms for Child #5 and #6 and submit copies by POC due date of 09/28/21.

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:Trevino Cochran
LICENSING EVALUATOR NAME:Rita Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 09/14/2021 02:19 PM - It Cannot Be Edited


Created By: Rita Ramos On 09/14/2021 at 11:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 due to not having an LIC 9227 for Child #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2021
Plan of Correction
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Per Licensee, a copy of the LIC 9227 will be submitted by POC due date of 09/28/21.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Rita Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267
VISIT DATE: 09/14/2021
NARRATIVE
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a cellphone that is used. LPA advised the Licensee that the cellphone has to stay at the facility during operation hours. There is ventilation and heating (central). Safe toys play equipment and materials were observed.

When inspecting the kitchen area at 9:09AM, LPA observed that there was a can of Raid ant and roach killer (poison) and other detergents, cleaning compounds, and other items which could pose a danger to children under the sink in a cabinet. LPA advised Licensee that all poisons need to be locked with key or combination lock. In addition, the cabinet was not latching due to one of the latches being broken. This poses an immediate health and safety risk to children in care. The restroom that children use was observed to be safe and sanitary.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 05/18/21, as indicated on service receipt. Smoke and carbon monoxide detectors were tested and are operable.

Licensee states that she is currently caring for infants. Licensee states that infants sleep in the bedroom where they are constantly supervised. Appropriate sleeping arrangements and cribs were observed. Cribs or play yard did not hinder the entrance or exit from the sleeping space. Cribs and play yards were observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee. Licensee did not have a sleeping log for all infants in care or an LIC 9227 form for Child #4 during the inspection.

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-and-resources/safe-sleep as an additional resource. ------Page 2 of 5

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267
VISIT DATE: 09/14/2021
NARRATIVE
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 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.

During the inspection, at 9:15AM, LPA observed that children are using the front yard for outdoor play. The front yard is being used due to the backyard being under construction. Licensee did not notify the department of the construction. The Licensee also did not notify the department that an area that is off-limits (front yard) will be used during the construction. LPA observed that there is a temporary metal fence with green mesh and protruding bars at the bottom being held by sand bags and no barricade to make the backyard inaccessible. LPA observed open and under construction garage. The construction poses an immediate health and safety risk to children in care (pictures were taken). The licensee states that supervision is being provided in the front yard. LPA inspected the front yard and observed rose bushes that are not covered or barricaded and advised Licensee that the rose bushes are hazardous due to the thorns.



The licensee is observed to be operating within the license capacity limitations. LPA did not observe any children left in parked vehicles. Car seats shall only be used for transportation. LPA did not observe any children sleeping in car seats.

The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 03/2023. There are first aid supplies available. LPA advised that if a child shows signs of illness they shall be separated from other children.

Children’s records were reviewed, including emergency information and were observed to be complete, however, Licensee did not have a file for Child #5 & #6.

The licensee and assistant do have proof of immunization against influenza, pertussis, and measles.

LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file.All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 07/23/21. ----Page 3 of 5
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267
VISIT DATE: 09/14/2021
NARRATIVE
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There are no pets on the premises.

LPA did not observe any pools, spas, hot tubs, fish ponds, or similar bodies of water during the inspection.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.

LPA did observe 2 baby walkers, one in the closet and one in the backyard. LPA advised Licensee to ensure that no baby walkers can be on the premises.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the
home.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process



The following deficiencies listed on the attached deficiency page are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

-----Page 4 of 5

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VILLAGRAN FAMILY CHILD CARE
FACILITY NUMBER: 198016267
VISIT DATE: 09/14/2021
NARRATIVE
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A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee/Director.


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

Exit interview conducted and report was reviewed with the licensee, Celest Villagran.

-----Page 5 of 5

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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