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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604143
Report Date: 04/17/2025
Date Signed: 04/17/2025 11:29:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2021 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20210923101017
FACILITY NAME:OCEAN HILLS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
374604143
ADMINISTRATOR:JOHNSTON, SHERYLFACILITY TYPE:
740
ADDRESS:4500 CANNON RDTELEPHONE:
(760) 295-8515
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:123CENSUS: 106DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Sheryl JohnstonTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not administer medications as prescribed by a physician
Staff falsified resident’s medication administration record
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston and Resident Care Director Dennis Prejusa.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review, and a tour of the facility. It was alleged that staff falsified resident’s medication administration record and staff did not administer medications as prescribed by a physician, specifically for Resident 1 (R1). The Department was unable to interview R1 due to R1 passing away in October 2021. Review of R1’s medical assessment and reappraisal records from 2020 revealed that R1 did not have a diagnosis of cognitive impairment, was diagnosed with a major neurocognitive disease (MND), but was not confused or disoriented, was able to follow directions, and required assistance with medication management.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/17/2025
NARRATIVE
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Interviews with staff (S1 – S4) and outside sources (OS1 – OS3) revealed that R1 was prescribed an anti-psychotic medication for R1’s diagnosis of MND and the medication came in a 30-day supply. Interviews with staff (S1-S4) and outside sources (OS1, OS2) revealed that facility management became aware that R1’s medication had not been reordered from the pharmacy when R1’s family notified facility management during a care conference on 8/16/2021. Interviews with staff (S2, S3) revealed that the facility conducted an internal investigation which revealed that R1’s anti-psychotic medication supply ran out on 7/19/2021. Interviews with outside sources (OS1, OS2) revealed that R1’s medication should have been refilled on 7/1/2021, but the medication was never ordered. Interviews with staff (S2, S3) revealed that R1’s family was responsible for supplying R1’s medications, however, those staff members did state that it was ultimately the facility’s responsibility to ensure that all residents, including R1, had a large enough supply of medications to maintain proper administration. Despite R1’s medication not being ordered, interviews with staff (S1 – S3) revealed that R1’s medication administration record (MAR) did not show any missed doses. The Department was unable to obtain R1’s MAR for verification due to the facility no longer having those archived records. Medication technicians were interviewed by facility management and the Department, and those interviews revealed discrepancies regarding how R1 received the medication. Interviews with staff (S1, S3) revealed that sometime between 7/19/2021 and 8/19/2021, R1’s anti-psychotic medication was stored in a paper envelope. Interviews with facility staff (S1, S3) further revealed that medication technicians assumed that R1’s medication was being repackaged or reordered. As part of the internal medication audit conducted by facility management, it was determined that another resident (R2) had a discontinued prescription for the same anti-psychotic medication that was prescribed to R1 and that R2’s medication supply was missing approximately 9 pills. Interviews with S2 also revealed that a staff member (S6) admitted to giving R1 anti-psychotic medications from R2’s discontinued medication supply.

The Department has investigated the above-mentioned allegations and based on interviews, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. Executive Director provided POC documents during the visit and LPA Borunda was able to clear the deficiencies during the visit.

An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)… facility staff… shall be permitted to assist the resident with self-administration, provided…(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not met as evidenced by:
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Executive Director stated that the facility terminated the staff that falsified the MAR and knowingly gave R1 medication that was prescribed to R2 in 2021. The Resident Care Director at the time conducted an inservice training for staff regarding medication administration on 9/24/2021 and requested
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Based on interview, the licensee did not comply with the section cited above in that R1 did not receive medications as prescribed. This poses a potential health risk to 106 of 106 residents in care.
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a 3rd party audit that was completed on 9/8/2021. Executive Director provided LPA with a copy of the inservice training for staff and the 3rd party audit during the visit.

Deficiency cleared during visit.
Type B
04/17/2025
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident…
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Executive Director stated that the facility terminated the staff that falsified the MAR and knowingly gave R1 medication that was prescribed to R2 in 2021. The Resident Care Director at the time conducted an inservice training for staff regarding medication administration on 9/24/2021 and requested
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This requirement has not been met as evidenced by: Based on interview, the licensee did not comply with the section cited above in that R1’s MAR was falsified. This poses a potential health risk to 106 of 106 residents in care.
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a 3rd party audit that was completed on 9/8/2021. Executive Director provided LPA with a copy of the inservice training for staff and the 3rd party audit during the visit.

Deficiency cleared during 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.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2021 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20210923101017

FACILITY NAME:OCEAN HILLS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
374604143
ADMINISTRATOR:JOHNSTON, SHERYLFACILITY TYPE:
740
ADDRESS:4500 CANNON RDTELEPHONE:
(760) 295-8515
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:123CENSUS: 106DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Sheryl JohnstonTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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lack of supervision resulted in Resident sustaining multiple injuries and hospitalization
Staff stole resident’s medication
Staff did not treat resident with dignity
Staff did not keep resident’s room clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston and Resident Care Director Dennis Prejusa.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review, and a tour of the facility. It was alleged that lack of supervision resulted in Resident 1 (R1) sustaining multiple injuries and hospitalization. The Department was unable to interview R1 due to R1 passing away in October 2021. Review of R1’s appraisal documents from 2019 revealed that R1 did not have any cognitive impairment, did not require any additional status checks, was independent for all activities of daily living (ADLs) and self-administered their own medications.

Continued on LIC9099-C page…
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/17/2025
NARRATIVE
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Review of R1’s medical re-assessment from 2020 revealed that R1 was diagnosed with a major neurocognitive disease (MND), had a history of falling and difficulty walking, was non-ambulatory, was unable to transfer in and out of bed independently, did not have any cognitive impairment, and was able to follow directions and communicate needs. On 6/29/2021, R1 was reassessed to need additional care, and required medication management, 1 person assistance for bathing, dressing, grooming, toileting, transfers, and ambulation and two-hour checks for toileting care. R1 was also deemed to be a fall risk during that reassessment. Interviews with staff and an outside source (S2, S4, OS3) supported that R1 was a fall risk. Review of incident reports submitted to the Department by the facility revealed that starting in mid-July 2021, R1 began falling while in their apartment. On 7/31/2021, staff responded to R1’s apartment and observed R1 to have an abrasion on the head. R1 complained of head and buttocks pain, resulting in R1 being transported to the hospital via emergency services and returned approximately 12 hours later. On 8/3/2021, staff found R1 on the floor of their apartment and observed R1 to have a mark on their head, however R1 denied knowledge of how they fell and did not complain of pain. Due to the potential head wound, staff called emergency services and R1 was transported to the hospital for medical attention. During both falls on 7/31/2021 and 8/3/2021, R1 notified staff of their fall via call pendant. On 8/13/2021, R1 was observed by facility staff to be non-responsive and to have a change in condition, resulting in R1 being transported to the hospital for assessment. Review of medical records dated 8/13/2021 revealed that R1 was diagnosed with general weakness. The discharge paperwork did not document a specific cause for R1’s weakness, however, medical professionals denied concern for a life-threatening cause. Those medical records also ruled out any fractures or head trauma.

On 8/16/2021, a care conference was held with facility staff and R1’s responsible parties to discuss R1’s change in condition. During that care conference, R1’s responsible parties informed facility management that R1’s anti-psychotic medication had not been refilled on 7/1/2021. Review of documents submitted to the Department revealed that the anti-psychotic medication was prescribed to R1 to manage hallucinations and delusions. Interviews with staff and outside sources revealed that R1’s medication administration record (MAR) was falsified by facility staff to show that R1 had received the anti-psychotic medication as prescribed, which was directly contradicted by interviews with staff who estimated that R1 did not receive their medication from approximately 7/19/2021 to 8/8/2021.

Continued on LIC9099-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/17/2025
NARRATIVE
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Interviews with staff (S2) and an outside source (OS3) revealed that while R1 not receiving their anti-psychotic medication could have contributed in R1’s increased falls, R1’s declining condition would have also contributed to R1’s falls. R1 was already deemed a fall risk from R1’s assessment records dated 6/29/2021 and an outside source (OS3) stated that R1 moved quickly. OS3 also recalled observing facility staff visually checking on R1 more often. S2 stated that R1 was already declining when R1 was admitted to the facility, which was supported by the increasing care needs documented in R1’s reassessment records on 1/11/2020 and 6/29/2021. During the care conference on 8/16/2021, facility management and R1’s responsible parties discussed R1’s increasing care needs and it was decided to have R1 assess for hospice care, which began on 8/19/2021. Interviews with facility staff and outside sources (S2, S3, OS1, OS2) revealed that R1’s anti-psychotic medication was refilled and R1 began receiving their medication as prescribed on 8/19/2021.

Incident reports received by the Department from the facility documented additional falls after the care conference and R1’s admission to hospice in late August 2021. On 8/26/2021, R1 was found by facility staff on the floor of R1’s bedroom. R1 did not push their pendant, did not recall how or why they fell, and did not complain of any injuries or pain. On the same day, 8/26/2021, R1 was found by facility staff on the floor again, approximately 50 minutes after R1’s previous fall. R1 did not complain of any pain or injuries during that fall incident either. Hospice was notified of both falls on 8/26/2021. On 8/27/2021, R1 pushed their call pendant and was found by staff on the floor of their apartment. R1 stated that they were attempting to go up the stairs, which the incident report noted that R1’s apartment did not have any stairs. Interviews with staff (S4) and review of documents provided by outside sources revealed that R1 was experiencing increased visual hallucinations in August 2021. Interviews with facility staff and outside sources (S2, S3, OS1, OS2) stated that after R1’s multiple falls between July and August 2021, it was recommended for R1 to have a one-on-one caregiver for supervision 24 hours a day. Interviews with staff (S2-S4) revealed that R1 began receiving one-on-one caregiver for 12 hours a day from 8/27/2021 through 8/29/2021. Interviews with staff (S2-S3) revealed that there was a miscommunication between facility management and R1’s responsible parties regarding how the private caregiver would be funded, resulting in R1 not receiving one-on-one supervision on 8/30/2021 or 8/31/2021. On 9/1/2021, R1’s hospice agency requested a psychiatric evaluation to assess R1 for psychosis caused to major neurocognitive disease and sleepwalking.

Continued on LIC9099-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/17/2025
NARRATIVE
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It was alleged that staff stole resident’s medication. Interviews with staff (S1 – S4) and outside sources (OS1 – OS4) revealed that R1 was prescribed an anti-psychotic medication for R1’s diagnosis of MND and the medication came in a 30-day supply. Interviews with staff (S1-S4) and outside sources (OS1, OS2) revealed that facility management became aware that R1’s medication had not been reordered from the pharmacy when R1’s family notified facility management during a care conference on 8/16/2021. Interviews with staff (S2, S3) revealed that the facility conducted an internal investigation which revealed that R1’s medication supply ran out on 7/19/2021 and the medication was not reordered. Interviews with staff and outside sources (S3, OS1, OS2) revealed that there were some concerns that R1’s medications were stolen for sale or illicit purposes due to the medication’s high cost, however, S3 stated that the medication was not a narcotic. Interviews with staff (S1-S4) did not reveal any evidence that the medications were stolen or taken from the facility. Interviews with staff (S1-S4) revealed that R1 was administered medications that were stored in a paper envelope. The facility’s internal medication audit revealed that the facility had a supply of the discontinued medication from Resident 2 (R2) which were missing approximately 9 pills. Interviews also revealed that a staff member (S6) admitted to taking medication from R2’s discontinued medication supply to administer to R1. The Department was unable to obtain any evidence that supported the allegation that R1’s medication was stolen from the facility by staff or any other individuals.

It was alleged that staff did not keep resident’s room clean. Interviews with residents (R2-R4) revealed that the facility offers weekly housekeeping and laundry services which include sweeping, mopping, vacuuming, and cleaning the bathroom. Outside sources (OS1-OS2) stated that facility staff did not clean R1’s room, including after R1 sustained injuries resulting in blood falling on the floor. While photographs taken by the Department did reveal a stain on the carpet of R1’s room, the stain was slightly discolored from the original color of the carpet and was isolated to a small portion of the room. Interviews with maintenance staff (S5) revealed that maintenance staff would assist housekeepers with housekeeping services when there were any gaps in the housekeeping schedule. S5 also stated that certain tasks such as carpet and spot cleaning were done when a work order was placed for the service. Residents interviewed did not reveal any issues with the timing or quality of the housekeeping services that were provided by the facility.

Continued on LIC9099-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20210923101017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/17/2025
NARRATIVE
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It was alleged that staff did not treat resident with dignity. Interviews with staff and outside sources (S1-S4, OS1-OS3) revealed that R1 was prescribed an anti-psychotic medication for hallucinations related to R1’s MND diagnosis. Interviews with staff (S1, S4) and information provided by outside sources (OS1-OS2) revealed that R1 experienced visual hallucinations while living at the facility, and that R1’s hallucinations were increasing in frequency. Additionally, incident reports submitted to the Department by the facility revealed that during at least two of R1’s falls between July and August 2021, R1 made statements that could not have happened, such as claiming that R1 was attempting to climb the stairs in R1’s apartment prior to falling, which both the incident report and visual tours of the facility revealed that all resident apartments do not have any stairs. Outside sources and staff (OS1-OS2, S4) also stated that R1 made comments about seeing animals or insects that were not there or wanting to go to locations like the basement, which the facility or R1’s apartment did not have.

Outside sources (OS1-OS2) stated that R1 informed them that on 8/13/2021, R1 did not want to get out of bed and two unidentified female staff pulled R1’s bedsheets off and pulled R1’s pants down in an effort to get R1 to get up. Review of incident reports submitted to the Department showed that on the same date, R1 was observed by facility staff to be weak, non-responsive, and did not want to get out of bed, resulting in facility staff calling emergency services. R1 was transported to the hospital for assessment and was diagnosed with general weakness. The discharge paperwork did not document a specific cause for R1’s weakness, however, medical professionals denied concern for a life-threatening cause. Those medical records also ruled out any fractures or head trauma. On 9/1/2021, R1’s hospice agency requested a psychiatric evaluation to assess R1 for psychosis caused by MND and sleepwalking. Interviews with staff and outside sources estimated that R1 did not receive their anti-psychotic medication from approximately 7/19/2021 to 8/8/2021.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8