304314174-10-3-2023-06-CC-NKTN-CW9VLE-20231003163150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314174
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:32:06 PM

Document Has Been Signed on 10/03/2023 04:32 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:	HERRERA CAMACHO, ELIANA		FACILITY NUMBER:	304314174
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	10/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Eliana Herrera Camacho, Licensee		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/03/2023, Licensing Program Analyst (LPA) Tran conducted an announced, in-person Pre-Licensing inspection for a new Small Family Child Care home. The LPA met with applicant Eliana Herrera Camacho and Hugo Cibrin Morales, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates 2 adults live in the home. The adult resident(s) received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are zero minors living in the home. The applicant stated that she is not registered with any Resource Foster Care agency and that she does not hold a Resource foster parent license. The applicant was reminded to notify the licensing office of any changes. The applicant is requesting a Small Family Childcare Home license. Per the applicant, operation hours will be Monday to Sunday, 5am-4am Care and supervision will be provided to children ages month old to 13 years old. For the purposes of licensing, an infant is defined as any child 0 to 24 months of age. All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a single-story home with 3 bedrooms, 2 bathrooms, a living room, a family room, a kitchen, a laundry room, a front yard (not fenced), a backyard (fenced), and a garage. There is a fireplace, located in the family room, barricaded by a metal screen. There are no stairs in the home Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated the 3 bedrooms, kitchen, laundry room, garage and patio area adjacent to outside of the garage and the laundry room on the left side of the home. The applicant has a child-proof safety gate to separate the backyard and the off-limit patio, and a child-proof safety gate to separate the dining room and the kitchen. The applicant has a lock on the door of the bedrooms ensuring this area is inaccessible to the children in care. (Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 2 of Report)

The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

Areas Designated for Day Care Activities: The applicant has designated the living room, dining room, family room and the bathroom on the right of the hallway, and back yard as the day care areas. The children will be napping in the family room.

Garage will not be used for day-care. The applicant stated the garage will be off-limit.

Garage is to be utilized for limited activities, day-care children are not to napped or eat in the Garage.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. The applicant has a small step tool in the children’s bathroom. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed. Smoke and carbon monoxide detectors were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed in the laundry room next to the kitchen and in the family room. There are no pet in the home.
(Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 3 of Report)

OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard. The backyard is appropriately fenced. LPA observed age-appropriate play equipment to be free from hazards. There are no bodies of water on the premises.

The applicant stated she will provide food for the children. The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Per the applicant, children will nap in the family room. Children will nap on cots and infants in cribs/play yards. The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

The applicant stated that licensee will provide linens and blankets for napping. The applicant stated that parents will provide diapers, lotion, wipes, and formula for the infants. Per the applicant, a changing table will be used to change diapers. Document where the changing table is located in the family room. LPA advised the applicant to always supervise at all times infants when changing their diapers.

A records review indicates the applicant completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 02/11/2025. A first aid kit is available at the facility family room.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

Only during Covid-19 outbreak, the applicant will receive children at the front door. Per the applicant, upon arrival children’s temperature will be taken, their hands will be sanitized, and the children will be taken to the designated day care area by the applicant. COVID-19 guidelines and precautions were discussed with the applicant.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 10

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 4 of Report)

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1. Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.

No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, 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.
(Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 4 of 10

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

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(Page 5 of Report)

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

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 applicant has submitted proof of immunization.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.

The LPA advised the applicant(s) on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 5 of 10

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

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(Page 6 of Report)

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.

STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record Exemption Transfer Request (LIC 9188).

(Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 6 of 10

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: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 8 of Report)

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). ). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Applicant,was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Landlord Consent

The applicant, has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 or 12 children. (Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 9 of Report)

Incidental Medical Services Plan (IMS)

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (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 Incidental Medical Services (IMS) - Family Child Care Homes

Review of records to be maintained:

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Safe Sleep

LPA discussed the safe sleep regulations with the applicant 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. LPAs also informed the applicant 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.

(Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

NARRATIVE

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(Page 10 of Report)

Megan’s Law

On this date, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

MyChildCarePlan.org

Applicant was informed of the MyChildCarePlan.org site, 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.

Notice of Site Visit

A notice of site visit was given to applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit Interview
Exit interview conducted and report was reviewed with the applicant, Eliana Herrera Camacho.

Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

(Continue next page)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HERRERA CAMACHO, ELIANA	FACILITY NUMBER: 304314174
	VISIT DATE: 10/03/2023

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(Page 11 of Report)

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The Small Family Child Care Home was in compliance with Title 22 Regulations at the time of inspection. In the event additional requirements are needed, the applicant will be notified.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.

Appeal rights were provided. Exit interview conducted and report was reviewed with the applicant Eliana Herrera Camacho.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 10 of 10