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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701489
Report Date: 02/26/2026
Date Signed: 02/26/2026 04:05:45 PM

Document Has Been Signed on 02/26/2026 04:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CASA DORISFACILITY NUMBER:
342701489
ADMINISTRATOR/
DIRECTOR:		ANI DARBINYANFACILITY TYPE:
740
ADDRESS:8533 LIQUID AMBER WAYTELEPHONE:
(916) 670-0370
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 4DATE:
02/26/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Staff on dutyTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On February 26, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management – annual continuation visit. This is a continuation of the annual inspection visit that was initiated on February 23, 2026. LPA met with staff on duty, Tammar Guthrie, and stated the purpose of the visit. The licensee, Beatrice Clark, was notified and arrived later.

Upon arrival, there were 4 residents in care with 1 staff on duty. The other staff arrived later around 1000 hours.

During this visit, LPA conducted another physical inspection of the facility. Hot water temperature was at 125 degrees Fahrenheit. Later today, Beatrice adjusted the hot water tank and the hot water was measured at 116 degrees Fahrenheit.

LPA conducted resident record reviews. Based on reviews of Medical Assessments (LIC602A), at least two residents (R1 and R2) were assessed to be at risks if they have access to the following items: personal care and hygiene items, disinfectants, cleaning solutions, knives, sharp objects, nutritional supplements, vitamins, and other toxic substances or similar items that could pose danger to residents.

LPA conducted review of staff files: Beatrice Clark's file was not available for review. 3 care staff did not have their first aid/CPR certificate on file for review.

LPA requested copy of the following facility documents: updated Liability Insurance, current Personnel Record (LIC500), and updated Designation of Responsibility (LIC308).

Deficiencies are being assessed base on today's visit and on the February 23, 2026 visit. Civil penalties are being assessed based on repeat violation and background clearance violation.

Exit interview was conducted with Beatrice Clark and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2026
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 21
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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Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations on 2/23/2026 and 2/26/2026 , the licensee did not comply with the section cited above. Hot water temperature readings were between 122 degrees F and 125 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Corrected during this visit, Licensee adjusted the hot water tank and LPA rechecked and was within regulation.
Per discussion, Licensee agreed to check hot water once a week and document it.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. During the visit on 2/23/2026, LPA found two resident medications inside the kitchen refrigerator that were accessible to residents. Also, the medication cabinet doors were not secured and LPA was able to open the cabinet doors without using the magnetic key; part of the magnetic lock was secured by tape/adhesive. These pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Corrected during site visit on 2/26/2026, Licensee brought a medication box with a lock for the medications that require refrigeration. Licensee secured the magnetic locks with screws during this visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above. During site visits on 2/23/2026 and 2/26/2026, 3 current staff do not have their first aid/cpr certificate on file for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Per discussion, Licensee agrees to submit the first aid/cpr certiicates for the 3 staff that are missing in their files. Submit documents by POC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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. During site visit on 2/23/2026, all staff files were not available for review upon request. During site visit on 2/26/2026, Beatrice Clark's file was not availbe for review upon request.This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Per discussion, Licensee agrees to submit a written of understanding of the regulation relating to personnel records; shall be submitted 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

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. During site visit on 2/23/2026, staff files were not availabe at the facility and documents of their crmininal records clearance was not available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Per discussion, Licensee agrees to submit a written of understanding of the regulation relating to personnel records; shall be submitted by POC due date.
Type B
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

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. During site visits on 2/23/26 and 2/26/26, there were no hospice training records provided by hospice professionals available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Per discussion, Licensee agrees to obtain hospice training provided by the qualified hospice nurse/licensed professional. Submit proof of training 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on (interview) and (record review), the licensee did not comply with the section cited above. Licensee did not have a signed admisson agreement for 1 of 4 residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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4
Per discussion, Licensee agreed to submit a signed admission agreement by POC due date. If resident or their responsible party refuse to sign the admission agreement, Licensee will submit a documentation that a meeting was held with the resident and their responsible party.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record reviews, the licensee did not comply with the section cited above. Not all residents have centrally stored medication records on file. Beatrice Clark stated she does not have these records for all residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Per discussion, Licensee agreed to start documenting residents' centrally stored medication records for each residents.
Licensee agreed to submit a written statement of understanding of the regulation cited 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
Page: 6 of 21
Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on(record review), the licensee did not comply with the section cited above. 4 of 4 residents did not have a PRN Authorization Letter on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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3
4
Per discussion, Licensee agreed to obtain a signed PRN Authorization Letter from each of the 4 resdients' physicians, submit documents to the Department by POC due date.
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on (interview) and (record review), the licensee did not comply with the section cited. Facility do not maintain administered PRN records since licensure, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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2
3
4
Per discussion, Licensee agreed to submit a written statement of understanding of the regulation cited 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 04:05 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/26/2026 at 01:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DORIS
FACILITY NUMBER: 342701489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department .

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and reviews of Guardian and LIS, S2 was present at this facility on 2/23/26 without association clearance to this facility. This poses immediate safety, health and personal rights risks to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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2
3
4
During site visit on 2/26/2026, S2 was not present at the facility. LPA instructed Licensee that S2 needs to have clearance from the Department before S2 can come back to this facility.
Note that this is a repeat violation. On 9/16/25 visit to this facility, as part of the POC, Licensee has agreed to complete the fingerprint or background clearance for all staff before allowing them access to the facility and submitted a Memo of Understanding.
Type A
Section Cited
CCR
87309(a)
The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the regulation cited above. During inspection visit on 2/23/2026, LPA found a knife inside the dishwasher and was accessible to residents; the garage was unlocked and found laundry detergents, floor cleaner and bleach that were accessible to residents in care; the Employee Room was unlocked and found vitamins, hygiene items inside the room and were accessible to residents. Per review of resident Physician's Reports, at least 2 residents in care were assessed to be at risk if they have access to the items listed above; disinfectants were observed under the bathroom sink. These pose immediate safety, health, and personal rights risks to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
1
2
3
4
Per discussion, Licensee agreed to submit a written statement of understanding of the regulation cited 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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