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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300339
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:22:56 PM

Document Has Been Signed on 12/06/2024 04:22 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:CREATIVE LEARNING CENTERFACILITY NUMBER:
376300339
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ,MARIAFACILITY TYPE:
850
ADDRESS:650 DOUGLAS DR #101TELEPHONE:
(760) 805-6478
CITY:OCEANSIDESTATE: CAZIP CODE:
92058
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 18DATE:
12/06/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Rebecca Morales and Maria HernandezTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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 On the above date and time listed Licensing Program Analyst’s (LPA’s), Kelly Gerth and Gabriela Hernandez arrived unannounced at the facility to conduct an annual inspection as part of a compliance review.
This is a combination childcare center, and the other licensed programs are: 376300340 which were also inspected on this date on this date. A tour of the inside and outside of the facility was granted and the following was observed and/or noted:

· The following items were posted and updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
- Menu
· The facility is operating within the limits as stated on the license.
· Ratios are being met during this inspection 18 Children and 3 Teachers present
· Classrooms are adequately equipped with age and size appropriate furniture
· There are no weapons present at the facility as stated by Facility Representatives Rebecca Morales and Maria Hernandez.
· There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Drinking water is provided in the indoor and in the outdoor activity space by filtered water pitcher and children’s water bottles.
· Medications are stored where inaccessible to children Front office in locked cabinet.
· Hazardous items were not stored where inaccessible to children which include disinfectants, cleaning solutions and other items that are dangerous, and Facility Representative Rebecca Morales was asked to remove the items during the inspection. The items were placed out of reach of children in care.
See Next Page
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 02:11 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 count, In the forward facing left corner of Grasshopper classroom, spray foam (used to cover hole in the wall, Per Facility Representative R Morales) is peeling and 1 inch and larger pieces have been picked off in spots and the spray foam material is unsafe/hazardous which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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By POC Date, Licensee agrees to submit proof that the spray foam areas has been made inaccessible to children in care and the area is in good repair, to CCL by COB.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 1 out of 4 persons [S3] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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By POC Date, Licensee agrees to submit proof of missing documentation referenced in citation, to CCL by COB.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 02:11 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting.

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 2/4 Staff were not associated to the facility and did not have proof of clearance, LPA verified clearance in guardian as both are still associated to previous employer (S3, S4)which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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By POC Date, Licensee agrees to submit proof of association of all employees of CCC, to CCL by COB.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 2/4 Staff Files reviewed did not have proof of TB Test ( S3, S4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, 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.
SUPERVISOR'S NAME:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 02:11 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 2/12 Childrens records reviewed (C8, C12),do not have proof of medical assessment /physicans report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, by POC date.
Type B
Section Cited
CCR
101220(b)(2)
Child's Medical Assessments
(b) The medical assessment shall provide the following: (2) Results of a test for tuberculosis.

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 4/12 Childrens records reviewed do not have proof of TB (C5, C8, C11,C12) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, 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.
SUPERVISOR'S NAME:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 02:11 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing 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 3/12 childrens files reviewed (C3, C4, C11) did not have proof immunizations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, by POC date.
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

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 2/12 Childrens records reviewed did not have a complete and signed LIC 700 /Identification form on file (C3, C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, 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.
SUPERVISOR'S NAME:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 20
Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 02:11 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

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 1/12 childrens files reviewed did not have a signed consent for emergency medical treatment form on file, (C9) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:22 PM - It Cannot Be Edited


Created By: Kelly Gerth On 12/06/2024 at 03:00 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
(2) Each person specified in (g) above shall have a health screening report signed by the person performing the screening.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2/4 staff files reviewed did not have a health screening report (S3, S4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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2
3
4


Director agrees to obtain proof of missing documentation referenced in citation and submit to LPA via email, by POC date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Kelly Gerth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


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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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339
VISIT DATE: 12/06/2024
NARRATIVE
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  • All floors were observed to be clean at this time.
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment
· Food preparation area is clean, free of litter, rubbish, free of rodents and other vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste were observed to have tight-fitting covers kept on, and in good repair
· Sign in/Sign out record were reviewed and meets regulation requirements
· Disaster drills are conducted at least every six months – last drill conducted on 10/05/2024.
A review of staff and children's records were conducted as part of this evaluation.
· Children’s records were found to be incomplete during this inspection. A citation will be issued.
· Staff record review indicates that all staff present meet minimum qualifications for the position for which they were hired, however were found to be incomplete during the inspection. A Citation will be issued.
· A staff member is present with current Pediatric CPR/First Aid which expires on 10/2025.
· Opening and closing staff member’s CPR/First Aid expires on 10/2025.
· Director completed Health and Safety Training on 04/06/2021.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 2 Staff have not been associated to the CCC at this time but confirmed to be cleared through guardian.

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 them email inquiries to inspectionprocess@dss.ca.gov.

See Next Page
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339
VISIT DATE: 12/06/2024
NARRATIVE
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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/process.

Facility Representatives Rebecca Morales and Maria Hernandez were reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, prior to initial presence in a Child Care Center. 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
LPA referred Facility Representatives Rebecca Morales and Maria Hernandez. to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. .

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.

For IMS information see PIN 22-02-CCP.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, are available at: https://www.ada.gov/resources/child-care-centers/



Facility Representatives Rebecca Morales and Maria Hernandez 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.
On-line Licensing forms & regulations for a Child Care Center can be obtained on the Department’s website: www.ccld.ca.gov.
See Next Page
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: CREATIVE LEARNING CENTER
FACILITY NUMBER: 376300339
VISIT DATE: 12/06/2024
NARRATIVE
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Additionally, there is a link to “Receive Important Updates” located on the right side of the page, immediately above Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200

The licensee was asked to update the following documents, if applicable, and submit to licensing within 30 days:

1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made or file copy is more than 2 years old)
4. LIC 309 Administrative Organization (only if changes have been made or file copy is more than 2 years old)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made& current designation is on file)
See LIC809-D for cited deficiencies

During the exit interview, the Facility Representatives Rebecca Morales and Maria Hernandez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and this report was reviewed with the Facility Representatives Rebecca Morales and Maria Hernandez. Appeal rights were discussed and provided during the exit interview.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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