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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312343
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:15:41 PM

Document Has Been Signed on 10/23/2025 03:15 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BARAHONA, JOSE & BARAHONA, SANDRAFACILITY NUMBER:
304312343
ADMINISTRATOR/
DIRECTOR:		BARAHONA, JOSE & SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 486-3908
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
10/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Licensee Sandra BarahonaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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(Page 1)
An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Giselle Lucero. LPA observed licensee caring for a total of 6 children, in which are 2 infants and 4 preschool age children napping. Licensee was operating within the licensed capacity as specified on the license.

LPA observed an adult male in the kitchen. Licensee stated the adult male is her husband, Uri Rubio, who came to assist licensee meanwhile co-licensee Jose Barahona is out of the country for a family emergency. A review of the Facility Personnel Report Summary on this date indicates that Uri Rubio does not have criminal record clearance. Licensee stated Uri Rubio has been assisting for about 3 weeks and has not completed the fingerprint process. This is a violation of Health and Safety Code Section 1596.871. Type A deficiency will be issued along with a civil penalty of $500 will be assessed; see LIC 809D for deficiency.

During interview with Licensee Sandra, Licensee stated she no longer lives in the home. The only adults that live in the home is Licensee Jose Barahona and Licensee's other daughter. LPA informed Licensee Sandra, that the licensees that are listed on the license must be living in the home. LPA observed that the change in household was not reported to the office, a Type B deficiency will be issued . An updated application form must be submitted to the office to reflect this change. Facility Day care hours are 7:00am-6:00pm, Monday through Friday.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343
VISIT DATE: 10/23/2025
NARRATIVE
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During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates, locked doors and child proof covers on door knobs. The childcare area consists of living room, dining room, 1 bedroom and 1 bathroom that is located in the hallway. Licensee stated the children's primary area is the living room. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The facility does not have a fireplace. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (land-line and cellular service). Licensee stated they use a part of the backyard for outdoor play. There is a water fountain located in the front yard that was observed empty. There are no bodies of water on the premises.

During records review, LPA observed the licensees did not have a current roster of children in care. A sample of 6 Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated, there are 3 infants under 24 months enrolled in the childcare. LPA reviewed LIC 9227 Individual Infant Sleeping Plan for infants. During record review, LPA observed licensees did not have 15 minute sleep logs for 3 out of 3 infants, a type B deficiency will be issued.

During record review and interview, LPA observed last conducted fire drill was in April 2024. Facility has not conducted a fire drill within the past 6 months, a type B deficiency will be issued.

The licensees' Pediatric CPR/First Aid certification expires 01/14/2027. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensees were reviewed and within compliance, however proof of immunization records for Uri Rubio could not be provided, a type B deficiency will be issued.
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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343
VISIT DATE: 10/23/2025
NARRATIVE
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Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. During record review, LPA observed both licensees do not have a current mandated reporter certificate, a type B deficiency will be issued.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

In the areas that were evaluated, 1 Type A deficiency and 5 Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. HSC: Administration of Child Day Care Licensing 1596.871(c)(1)(A), HSC: Administration of Child Day Care Licensing 1596.8662 (b)(1), Infant safe sleep 102425(j)(2)(D)(c), Reporting requirements 102416.2(a)(2), Administration of Child Day Care Licensing 1597.622(c) and Operation of a family child care home 102417(g)(9)(A). See LIC 809D for the following deficiencies.

LPA Lucero informed licensee Sandra Barahona that this report dated 10/23/2025 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care
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Also, LPA Lucero informed the licensee to provide a copy of this licensing report dated 10/23/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343
VISIT DATE: 10/23/2025
NARRATIVE
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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.

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.

Exit interview conducted and report was reviewed with the licensee Sandra Barahona in Spanish. A notice of site visit was posted and must remain posted for 30 days.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 03/2022) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

End of Report.
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/23/2025 03:15 PM - It Cannot Be Edited


Created By: Giselle Lucero On 10/23/2025 at 01:52 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.2(a)(2)
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm).

(2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Licensee Sandra Barahona, the licensee did not comply with the section cited above. Licensee Sandra no longer resides in the home and it was not reported to the office. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Sandra stated she will move back in the home to not be removed from the license, LPA informed Sandra that if she cannot move back in, to submit an application form to reflect the changes on the license.
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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 03:15 PM - It Cannot Be Edited


Created By: Giselle Lucero On 10/23/2025 at 02:11 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in 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 Uri Rubio has not completed fingerprint clearance and has been assisting for about 3 weeks. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee stated she will have Uri Rubio complete his fingerprints today and will not return until clearance is received.
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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 10/23/2025 03:15 PM - It Cannot Be Edited


Created By: Giselle Lucero On 10/23/2025 at 02:11 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

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. A fire drill has not been completed within the last 6 months. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Licensee stated she will conduct fire drill and send documentation to LPA by POC due date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above 2 out of 2 staff did not have a current mandted reporter certificate. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Licnesee stated she will submit a current mandated reporter certificate to LPA 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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 03:15 PM - It Cannot Be Edited


Created By: Giselle Lucero On 10/23/2025 at 02:11 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: BARAHONA, JOSE & BARAHONA, SANDRA
FACILITY NUMBER: 304312343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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. Licensee has not completed sleep logs for 3 out of 3 infant. Licensee stated she was unaware a sleep log is needed for infants up to 2 years old. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Licensee stated she will submit sleep logs for 3 out of 3 infants to LPA by POC due date.
Type B
Section Cited
CCR
1597.622(c)
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above 1 out of 3 adults did not have a copy of immunization records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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2
3
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Licensee stated she will submit proof of immunization records for adult 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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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