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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364844287
Report Date: 09/03/2025
Date Signed: 09/03/2025 04:09:00 PM

Document Has Been Signed on 09/03/2025 04:09 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:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
364844287
ADMINISTRATOR/
DIRECTOR:		JACKSON, LATOYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 373-6251
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Latoya JacksonTIME VISIT/
INSPECTION COMPLETED:
04:09 PM
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On September 3, 2025, Licensing Program Analyst (LPA) Calloway made an unannounced inspection to the above facility. LPA met with Licensee, who granted access. LPA and Licensee toured the home inside and outside for an Annual Random inspection. Residing in the home are the Licensee, one adult and five minor children. The home is licensed for twelve to fourteen children. LPA observed no day care children in active care with licensee during inspection. Daycare hours are 6:00 AM-6:00 PM. Monday through Friday for 0- 12 years. All adults residing or working in the facility have Criminal Record Clearance (DOJ/FBI) and Child Abuse Central Index Clearance and are associated to the facility license. One day care child arrived later during the inspection.
Physical Plant: This is a two story four-bedroom, three-bathroom home with kitchen, dining room, family room, laundry room, and garage. Childcare is provided: in the dining room on the right upon entry. Children’s Bathroom: is in hallway on the left. It was observed to be clean, with soap, toilet paper, functioning sink and toilet. The cabinets were not locked and there were no items accessible as hazards. The unused outlets in the home were covered. There were no blinds only curtains. LPA observed toys, books, and furniture that were the appropriate height. Licensee stated there is no napping. The home was inspected inside and outside for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, hazardous conditions. The cleaning supplies are kept inside the laundry room locked. The medicines are kept in the kitchen off limits.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287
VISIT DATE: 09/03/2025
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The windows are screened, free of bugs, cracks, and debris. The fireplace is inside the living room observed screened with a glass covering. The home has central air conditioning and heat. The required postings were present on the parent wall. There is a landline phone, and cell phone. The stairs were gated. The temperature inside the home was comfortable. Fire and earthquake drills were not current. The fire drill was conducted: 12/24/24 and the earthquake drill was not conducted. Licensee stated they did not know there was a separate drill for disaster. The child and parent roster was current and complete with all required information. The fire extinguisher (2A:10BC) was full, and needle was inside the green area. The carbon monoxide detectors were tested as operable. The smoke alarm was not operable. Licensee stated they just realized it was not working. There was not an audible device observed. There was a single action door handle.

Kitchen: Inside the Kitchen, the sharp knives and other sharp utensils were locked inside an upper cabinet above the oven with a magnetic lock. Licensee stated meals and snacks are provided and there are no known allergies. The refrigerator and freezer were both working.


Off limit areas: Garage, all bedrooms and other bathrooms in the home, laundry room, and outside area of the yard was gated. LPA observed a trampoline in the gated area.
Outside: The backyard is completely fenced and locked. The fencing material was wood and in good condition. Licensee stated, there is a pet in the home. LPA observed one dog inside the home. Licensee stated the pet is vaccinated and does not interact with the day care children. Licensee stated there is an in-ground pool and spa as a body of water on premises. LPA did observe an in-ground pool and jacuzzi as a body of water on the premises. The pool fence was wrought iron and measured at 5 ft and constructed so that the fence does not obscure the pool from view. The bars between the pool fence are 3 1/2 inches apart. The larges gap is 2 inches from the bottom of the gate. The fence or gate swings away from the pool and has a self-close and self-latching device located no more than six inches from the top of the gate. There was a pool alarm, 17” life ring, and a body hook with a twelve-foot fixed pole observed during the inspection. There was not a safety log. Licensee stated they did not know they needed to have one. There is a shaded rest area with tables and chairs.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287
VISIT DATE: 09/03/2025
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 The air conditioning (AC) unit in the yard was observed in an off-limits area of the yard. Licensee stated the neighboring homes do not have in ground swimming pools or bodies of water. There was a swing and slide play structure. LPA did not observe cushioning material underneath. Licensee stated they did not know it was needed.

Other Review: Licensee stated, there are no weapons or firearms on the premises. LPA did not observe any. The mandated reporter training was viewed. CPR/First Aid (Exp: 3/2027), and immunizations were available and viewed. There is a First Aid kit inside the home. LPA viewed staff and children’s files. Licensee stated there are no infants in care. Licensee stated transportation is provided. Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed. Licensee stated, the home does not have daycare liability insurance. LPA conducted a staff interview with the Licensee.


The following was discussed with the Licensee:
Maintain capacity and transparency per posted parent rights, Roster requirements (keep updated information always and maintain information for three years), Documentation for disaster drills (fire and earthquake drill are conducted every six months). Maintain mandatory forms, signed, for the children’s/staff files, know the updated Safe Sleep regulations. The role and responsibilities of being a mandated reporter. Supervision is required for children in care. If food is brought in, it is properly labeled. Check food expiration periodically. Licensee is responsible for knowing the regulations as well as anyone who assists in providing care. Temporary absences shall not exceed 20 percent of the hours that the facility provides care per day. If day care is inactive for an extended period, you may notify Licensing. Inaccessibility of hazards must be constantly reassessed depending on the children in care. If the phone number is changed, or someone moves in or out of the home, licensing must be notified.

Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy rocker seats, exer saucers, bassinettes, and any other items that fall into that category. Safe Sleep regulations: require infants sleeping on their back unless specified with LIC 9227 form, no blankets, toys, or pacifiers attached to their clothing and Licensee will observe infants every fifteen (15) minutes and maintain a napping log.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287
VISIT DATE: 09/03/2025
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The Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare 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.

Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (printed out after every visit) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee shall provide a copy of any Type A deficiency to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in each of the children’s files for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.

=Licensee is advised to visit: www.shotsforschool.org for Immunization information.
=Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640. Licensee was informed of the MyChildCarePlan.org website, a
consumer education website that helps families obtain childcare by connecting them to child
care providers and Resource and Referral Agencies (R&Rs) throughout California.
=Family Child Care Providers (Disaster Planning information):
https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
=Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
=Child Care Videos: https://ccld.childcarevideos.org
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287
VISIT DATE: 09/03/2025
NARRATIVE
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=Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
=Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department prior to providing the IMS. 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: http://www.ada.gov/childqanda.htm.
=LPA discussed the safe sleep regulations with licensee 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 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.
=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.
=Lead Poisoning: For more information, view PUB 515 and go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.
Reminder: The CCLD On Duty Worker is available: Monday through Friday from 8:00 AM - 5:00 PM, at (661) 202-3318 for questions, information, and Unusual Incident Reporting. Once the incident is reported within twenty-four (24) hours via telephone, follow up with a written report via email to: unusualincidentreport@dss.ca.gov or via fax to: (661) 202-3810 within seven days of reporting.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287
VISIT DATE: 09/03/2025
NARRATIVE
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There is a Type A deficiency cited for Fire Clerance and an immediate $500.00 civil penalty. There are Type B deficiencies cited during this inspection and Technical Violations issued. See LIC 809D, LIC 9102 TV, and LIC 421IM pages attached to this report.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed acknowledgment of Licensing Reports (LIC 9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit, and Appeal Rights were provided to Latoya Jackson, Licensee during the inspection. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in $100 civil penalty. During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 04:09 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 09/03/2025 at 03:55 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: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

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 in the swings and slide did not have cushioning material underneath which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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I will provide proof by POC date
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review , the licensee did not comply with the section cited above in the fire and earthquake drill was not current during the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2025
Plan of Correction
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I will provide proof of drill by POC 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.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Kuliema Calloway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2025 04:09 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 09/03/2025 at 03:55 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: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 364844287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.99(c)(2)
§1596.99 Levy of civil penalty in addition to suspension, temporary suspension, or revocation; amounts; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, for any of the following serious violations: (2) Fire clearance violations, including, but not limited to, overcapacity, inoperable smoke alarms, and inoperable fire alarm systems.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in smoke alarm was inoperable during the inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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I will provide proof by POC date.
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.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Kuliema Calloway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2025


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