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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881005
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:59:08 PM

Document Has Been Signed on 11/21/2023 02:59 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:A AND E LOVING SENIOR HOME CARE, INC.FACILITY NUMBER:
361881005
ADMINISTRATOR:BERNARDO, RUSSELLFACILITY TYPE:
740
ADDRESS:14931 OAKSPRING DRIVETELEPHONE:
(909) 320-7888
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 6DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Licensee/Administrator Evafe Green – Sosnovsky and Administrator Russel BernardoTIME COMPLETED:
03:10 PM
NARRATIVE
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On 11/21/2023 at 08:32 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Administrator Russell Bernardo, was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Licensee/Administrator Evafe Green – Sosnovsky was contacted and arrived during the visit.

The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and one (1) may be bedridden and with approved hospice waiver for six (6). The current census is six (6) residents. LPA Brown was accompanied by Administrator Bernardo to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA Brown observed obstructions to outdoor passageways as the backyard was observed with unused grills, ladder, tables, chairs. Deficiency will be issued. In addition, LPA Brown observed cleaning supplies not locked in the laundry room and are accessible to residents in care. Deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed no non-skid mat or strips in the hallway bathroom. Deficiency will be issued. Also, the cleaning supplies storage cabinet lock was broken or in disrepair located in the laundry room making it accessible to residents in care. Furthermore, LPA Brown observed pre-poured residents medication for the whole day, not locked in the kitchen drawer. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by not locking the cleaning solutions/supplies located in the laundry room cabinet making it accessible to their residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee stated to immediately lock the cleaning solutions in the laundry room cabinet once and submit proof to LPA Brown at Plan of Correction (POC) due date.
Licensee stated to submit Signed Statement of Understanding on CCR 87309(a) to LPA Brown at POC due date.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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 by storing the residents whole day pre-poured medicines in the kitchen cabinet and not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee removed the pre-poured medicines found in the kitchen drawer and transferred it to a locked medicine cabinet during the visit.
Licensee stated to train all staff on CCR 87309(b) and submit proof of Training Log to LPA Brown at Plan of Correction (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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 by pre-pouring the residents whole day of medications in a small container per resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 by not securing or locking two (2) scissors found in the kitchen drawer not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee stated to train all staff on CCR 87705(f)(1) and submit proof of Training Log to LPA Brown at 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 by not locking the nutritional supplements or vitamins in the kitchen cabinet making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

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 by locking/securing the side gate/perimeter fence gate with a pad lock in a manner that residents are unable to exit without assistance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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The licensee agrees to remove the lock and agree to not lock the perimeter fence gate without Licensing and Fire Marshall approval. Administrator unlocked gate during visit. Plan of Correction (POC) cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 by not having non-skid mat or strip in the hall bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee stated to put/purchase a non-skid mat/strip in the hallway bathroom and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 by not having the Cleaning Supplies cabinet in good repair located in the laundry room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee stated to repair the Cleaning Supplies cabinet in the laundry room and submit proof of repair to LPA Brown at 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by not having the backyard/outdoor free of obstructions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee cleared the backyard/outdoor of obstructions during the visit. Plan of Correction (POC) cleared.
Type B
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

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 by not having Staff #4 (S4) and Staff #5 (S5) Health Screenings Report in their staff facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee stated to complete S4 and S5 Health Screening Report and update S4 and S5 file and submit proof to LPA Brown at 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 11/21/2023 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 11/21/2023 at 12:36 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 by having R3 with full bed rail and not having a written order from a physician indicating the need for the postural support and shall be maintained in the resident's record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee stated to submit a written order from R3's physician indicating the need for the postural support and maintain in R3's facility file and submit proof to LPA Brown at Plan of Correction (POC) date. Also, if Physician required full bed rail, Exception Letter must be submitted for approval to CCLD with a written order from a physician indicating the need for the full bed rail.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 by not having a Hospice Care Plan that specifies the need for full bed rails for Resident #1 (R1), Resident #2 (R2), Resident #5 (R5) and Resident #6 (R6) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee stated to submit R1, R2, R5 and R6 Hospice Care Plan that specifies the need for full bed rails and submit to LPA Brown at 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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
VISIT DATE: 11/21/2023
NARRATIVE
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 Also, LPA Brown observed Resident #3 (R3) with full bed rails and Administrator Bernardo reported to LPA Brown that R3 is not on Hospice Care and no written order from the physician was observed indicating the need for postural support. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R3's full bed rails. To add to that, LPA Brown observed Resident #1 (R1), Resident #2 (R2), Resident #5 (R5) and Resident #6 (R6) have full bed rails. Administrator Bernardo reported to LPA Brown that R1, R2, R5 and R6 were under Hospice Care but per documents review, LPA Brown observed R1, R2, R5 and R6 do not have Hospice Care Plan that specifies the need for full bed rail. Deficiencies will be issued. Moreover, during the tour of the facility, LPA Brown observed the side gate secured and locked with padlock. This poses immediate safety risk to residents in care. Deficiencies will be issued for locking/securing the side gate with padlock. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster and the disaster plan were posted in a common area.

Moreover, during the tour of the facility, LPA Brown observed two (2) scissors in an unlocked kitchen drawer, accessible to residents in care. Deficiency will be issued as this pose immediate safety risks to residents in care. There was a designated storage space for resident/staff files. There is a cabinet with the majority of the resident’s medications locked in the medication room. LPA Brown found medications pre-poured in a small container for the day, up to bedtime medication for each resident at the facility. LPA Brown explained that no medications shall be transferred between containers. The facility will be issued deficiencies for pre-pouring residents medications for the day as this pose immediate health, safety and personal rights risks to residents in care. To add to that LPA Brown observed Nutritional Supplements or Vitamins not locked and accessible to residents in care. LPA Brown informed Administrator Bernardo that deficiency will be issued as this pose immediate health and safety risks to residents in care.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 10 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
VISIT DATE: 11/21/2023
NARRATIVE
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Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPA reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that five (5) of the five (5) staff have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. However, LPA Brown observed two (2) of the five (5) staff do not have Health Screenings in their facility file. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, twelve (12) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Licensee/Administrator Evafe Green – Sosnovsky and Administrator Russel Bernardo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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