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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364818951
Report Date: 03/02/2026
Date Signed: 03/02/2026 02:40:38 PM

Document Has Been Signed on 03/02/2026 02:40 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GAMINO FAMILY CHILD CAREFACILITY NUMBER:
364818951
ADMINISTRATOR/
DIRECTOR:		GAMINO, MARIA A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 241-4218
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
03/02/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Maira Gamino, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On Monday, March 2, 2026, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with licensee Maria Gamino who granted access and guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPA observed two (2) infants, five (5) preschoolers, four (4) school-age children present, and assistant LPA observed facility to be within ratio. Operating hours are Monday to Friday from 7:30 am to 5:30 pm and care for children ages 0 to 13 years old. Annual fee is current.

This facility is a one-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, dining room, attached garage, and front and backyard fenced.

Areas off limits to children include- three (3) bedrooms (hallway), master bathroom, kitchen, dining area, and a section of the backyard.

Areas accessible to children include- attached garage (play only) bedroom (4) next to garage, the bathroom in the bedroom and back yard.

LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC/heater in the main house and a mini-split unit in playroom. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did not observe a fireplace in the daycare rooms. LPA observed play pens and observed to be free from bumper pads, blankets, pillows and hanging items.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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 12
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 03/02/2026 02:40 PM - It Cannot Be Edited


Created By: Mayra Rivera On 03/02/2026 at 01:15 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not documenting 15 minutes sleep logs for child #1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Licensee stated will start documenting today until child #1 turns 24 months and provide LPA proof of the 15 minutes sleep logs.
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2026 02:40 PM - It Cannot Be Edited


Created By: Mayra Rivera On 03/02/2026 at 01:20 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in child #3 and child #4 not having immunization record due to parents personl beliefs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Licensee stated will notify parents and provide them a copy of PIN 19-08-CCP California Department of Public Health /New Pre Kinger/Kindergarten and child care and school immunization requirements. Will inform parents child #3 and child #4 will not be able to attend care until proof is provided.
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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LPA Rivera observed cleaning compounds items, stored in the main house hallway cabinet with a child proof lock. LPA observed the knives and sharp objects stored inside the kitchen pantry and LPA observed a child proof lock on the doorknob making it inaccessible for children to open. The licensee stated she provides meals. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies or on medication.

LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has no pets, no poisons, no firearms, no weapons and no bodies of water. LPA did not observe pets, poisons, firearms, weapons or bodies of water. The licensee was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.



LPA Rivera observed the required 2A10BC fire extinguisher located daycare room and observed the valve on the green area indicating fully charged. LPA informed licensee the fire extinguisher must be service annually or show purchase receipt within a year. LPA observed a carbon monoxide detector located in the main house hallway and smoke alarm located in the daycare room. LPA tested the carbon monoxide and smoke alarm and heard the sound, and it is operable. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on September 21, 2025.

LPA Rivera inspected the play outdoor backyard area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced, and the side gates closed and locked with self-latch. LPA observe a small cactus plant behind the shed and LPA informed to place a gate barrier to prevent children touching the cactus. LPA observed play equipment to be age appropriate and did not observe high climbing equipment. LPA observed a shed and observed the shed to be closed and locked.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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LPA Rivera observed licensee American Red Cross Pediatric First Aid/ CPR certification dated April 20, 2024, and has proof of, immunization against Pertussis, MMR, and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter training dated April 15, 2024.

LPA observed the postings License, and Pub 394 Notification of Parents Rights. LPA observed children files. LPA observed child #3 and child #4 missing proof of immunization record. Licensee stated, “the parent does not want the children to be immunized”. LPA informed immunization requirement became effective July 1, 2019. Personal or religious beliefs does not apply anymore. LPA informed medical exemptions can only be issued by doctors (MDs or DOs) licensed in California and must meet applicable American Academy of Pediatrics (AAP) criteria.

LPA did not observe 15 minutes sleep logs for child #1. LPA asked licensee if she has completed the 15 minutes sleep logs for child #1 and licensee stated, “to be honest with you, no”. LPA informed 15 minutes sleeps logs are to be completed until the child turns 24 months. LPA provided a 15-minute sleep log.


The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee 80/20 a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), Child Abuse Mandated Reporter Certificate.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 8 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.



12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: 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 licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, 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.


NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 9 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA informed licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.



20. LIC 126 Checklist for Family Child Care provided and reviewed.

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.

Licensee Maria Gamino 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.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 10 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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LPA discussed the safe sleep regulations with licensee Maria Gamino and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Maria Gamino 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee Maria Gamino was informed of the MyChildCarePlan.org website; 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.

Licensee Maria Gamino, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiencies listed on the following page were observed by LPA Rivera and are being cited in accordance with California Code of Regulations Title 22 or Health and Safety code. Two type B deficiencies are being issued today for regulations Title 22. Please see attached LIC 809-D for citations.



102425(j)(2)- The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document.

102418(a)- (a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

Two technical violations given.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GAMINO FAMILY CHILD CARE
FACILITY NUMBER: 364818951
VISIT DATE: 03/02/2026
NARRATIVE
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Due date March 13, 2026. A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report was reviewed with licensee Maria Gamino.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
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