<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
376100931
Report Date:
10/04/2023
Date Signed:
10/04/2023 03:04:49 PM
Document Has Been Signed on
10/04/2023 03:04 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
ADMINISTRATOR:
NERLANDE ALCEUS
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(619) 305-4485
CITY:
SAN DIEGO
STATE:
CA
ZIP CODE:
92115
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
4
DATE:
10/04/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:50 AM
MET WITH:
Nerlande Alceus
TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/4/2023 @ 11:50AM, Licensing Program Analysts (LPAs) Nancy Diaz and Martha Avila conducted an unannounced inspection. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. A tour of the home was conducted with Nerlande Alceus. Observed present today were three (3) children (all under age two). A school-age child arrived at 2:45PM. The following areas are accessible to children: living room, dining, kitchen, hallway bathroom, bedroom at the end of the hallway (to the right) and back fenced yard. Facility operates 7days/24hours. The licensee was present in the home to ensure that all children are supervised at all times. Facility is within capacity and did not exceed the capacity specified on the license.
There were no bodies of water observed present within the premises. Mrs. Alceus stated that she does not maintain weapons in the home.
Detergents, cleaning compounds, medications and other items which could pose a danger to children are stored appropriately and inaccessible to children.
Fire extinguisher and smoke detectors meet State Fire Marshall standards. The carbon monoxide detector present in the home meet the standards established in Chapter 8 of Part 2, Division 12. Home is kept clean and orderly with heating and ventilation for safety and comfort. Licensee provide toys, play equipment and materials. The home maintains a working telephone service.
There is a playpen for one infant who is unable to climb out. The playpen was observed to be free from all loose articles and objects. Bumper pads are not used. There are no objects hanging above or attached to the side of the crib. Infants are not swaddled while in care. Mrs. Alceus did not maintain sleep logs (15-minute checks).
SUPERVISORS NAME
:
Tashima Daniel
LICENSING EVALUATOR NAME
:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
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
9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
VISIT DATE:
10/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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-and-resources/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.
Car seats are only used for transportation purposes and not used for sleeping. Infants are supervised while they sleep.
The outdoor play area is fenced or supervised by the licensee. An isolation area has been designated for children who became ill during the day.
Licensee's records were reviewed. Mrs. Alceus has completed the mandated reporter training pursuant to Health & Safety Code. Licensee was made aware that the mandated reporter training shall be renewed every 2 years.
Staff have been immunized against influenza, pertussis and measles. Licensee’s CPR and First aid is valid thru December 2023.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
Incidental Medical Services (IMS) policy was discussed. For IMS information see
PIN 22-02-CCP
. 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/
.
SUPERVISORS NAME
:
Tashima Daniel
LICENSING EVALUATOR NAME
:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
2
of
9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
VISIT DATE:
10/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee 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.
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
.
LPA Diaz reminded Mrs. Alceus about her annual fee that was overdue.
Exit interview conducted and report was reviewed with Mrs. Alceus. A copy of report and appeal rights were provided to Mrs. Alceus. Notice of site visit was also given and observed posted. This notice shall remain posted for 30 days.
Megan’s Law - Family Child Care Homes
During the exit interview,Mrs. Alceus, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
TYPE B DEFICIENCIES WERE CITED. THESE ARE REPEAT VIOLATIONS.
SUPERVISORS NAME
:
Tashima Daniel
LICENSING EVALUATOR NAME
:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. The barricade at the bottom of the stairs in the back yard is broken, making the stairs accessible to children. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will fix the barricade in the backyard no later than 10/11/23.
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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Mrs. Alceus has not conducted a fire drill with the children since March 2023. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will conduct a fire drill with the children no later than 10/11/23.
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus failed to maintain the required sleep log (15 minute checks). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
LPA provided Mrs. Alceus a sample copy of the 15-minute nap log. She stated that she will keep track of the 15-minute nap check starting 10/5/23. She will maintain the sleep log everytime the infants nap until they turn 2 years old.
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
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus did not supervise napping infants. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will supervise napping infants immediately and maintain nap logs.
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceuse did not maintain children's immunization records. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
LPA provided Mrs. Alceus a packet of children's forms today. She stated that she will obtain children's immunization record and maintain the records onto the blue immunization form no later than 10/11/23.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus did not maintain a signed copy of LIC 995 on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
LPA provided Mrs. Alceus a packet of required children's forms. Mrs. Alceus stated that she will have parents complete the packet by 10/11/23.
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus did not maintain a copy of the emergency information card for the 3 children she has in care today. Mrs. Alceus did not know the name of one of the children in care today. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
LPA provided Mrs. Alceus a packet of the children's required forms. Mrs. Alceus stated that she will provide the parents a copy of the forms and maintain on file no laterthan 10/11/23.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus failed to maintain a current roster. None of the children present today were listed on the roster. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will update the children's roster to include all the names of children in care no later than 10/11/23.
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus did not maintain affidavits on file for the 3 children in care today. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
LPA provided Mrs. Alceus a packet of children's required forms today. Mrs. Alceus stated that she will have the parents complete the form no later than 10/11/23 and have them available for review by the department.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus did not maintain an infant sleeping plan for the 9-month old infant in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will provide the form to the parent and have them available for review by the department no later than 10/11/23.
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
8
of
9
Document Has Been Signed on
10/04/2023 03:04 PM
- It Cannot Be Edited
Created By:
Nancy Diaz
On
10/04/2023
at
02:00 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
,
7575 METROPOLITAN DR STE 110
SAN DIEGO
,
CA
92108
FACILITY NAME:
ALCEUS, NERLANDE FAMILY CHILD CARE
FACILITY NUMBER:
376100931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/04/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Mrs. Alceus failed to maintain a log of the 15-minute nap check for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2023
Plan of Correction
1
2
3
4
Mrs. Alceus stated that she will maintain a log of the 15-minute checks when infant naps and have them available for review by the department no later than 10/11/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Tashima Daniel
LICENSING EVALUATOR NAME:
Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE:
10/04/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/04/2023
LIC809
(FAS) - (06/04)
Page:
9
of
9