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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709398
Report Date: 03/12/2026
Date Signed: 03/12/2026 05:36:52 PM

Document Has Been Signed on 03/12/2026 05:36 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ADDISON PENZAK JEWISH COMMUNITY CENTERFACILITY NUMBER:
430709398
ADMINISTRATOR/
DIRECTOR:		CYNDI SHERMANFACILITY TYPE:
850
ADDRESS:14855 OKA ROADTELEPHONE:
(408) 357-7417
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 180TOTAL ENROLLED CHILDREN: 95CENSUS: 55DATE:
03/12/2026
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Cyndi Sherman - DirectorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
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On 03/12/2026, Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, conducted an unannounced 3-Year Required Inspection. Upon arrival, LPA was greeted by the Director, Cyndi Sherman, and provided access to the facility. The facility's hours of operation are Monday – Friday, 7:30AM - 5:30PM. There is an active waiver to commingle toddlers and preschoolers for the first and last hour of the day. There is another waiver for outdoor activity space as the facility has less than 75 square feet per child. LPA observed the waivers posted along with all required postings in the main office, accessible to authorized representatives.

LPA toured the facility and collected the census. There were 55 children present (47 - preschoolers and 8 - toddlers) and (16) staff (13 - Teachers, 2 - Aides, 1 - Director) present which is compliant with the capacity and ratio requirements.

Facility representative, Cyndi Sherman was 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, or transfer their existing 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.

All staff present had criminal record clearance and were associated to the roster on Guardian.

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out is completed digitally using the application, Procare.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398
VISIT DATE: 03/12/2026
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LPA observed sign in/out records to be complete. The last fire/disaster drill was conducted on 10/09/2025, which is compliant with the six month requirement for facilities.

LPA observed a fully charged 3A40BC fire extinguisher, last serviced 12/29/2025, which is compliant with State Fire Marshal regulations. LPA observed a fully functioning smoke detector system hardwired into the facility, along with a fully functioning carbon monoxide detector. There are no weapons or firearms on the premises.

The Director states that she currently does have children in care who require Incidental Medical Services and does administer medication at this time.

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/.

LPA observed six (6) out of eight (8) medications stored were expired. LPA observed one (1) out of eight (8) medications stored did not have written permission from an authorized representative.

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.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398
VISIT DATE: 03/12/2026
NARRATIVE
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Indoor areas were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Furniture is in good condition and safe for children and the floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via drinking fountains. Children bring reusable bottles from home labeled with their names. The facility offers a full day program. Children bring their food and water from home in containers labeled with their names. Cleaning solution was observed under the sink in an unlocked cabinet accessible to children. Staff removed the cleaner and placed it in an inaccessible area.

Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. There is a working telephone in the facility.

The outdoor area was inspected and observed to be fenced in. There is a playground, sandbox, activities and bikes for children. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (rubber) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by canopies and building overhang. LPA observed storage locker with landscaping tools including a rake was unlocked with the door open.

LPA discussed the safe sleep regulations with the facility representative 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 the facility representative 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.

Five (5) children’s files (2 - preschool-age and 3 - toddler age) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). LPA observed all files to be complete.


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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398
VISIT DATE: 03/12/2026
NARRATIVE
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Five (5) staff files (3 - Teachers, 1 - Aide and 1 - Director) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza or statement declining influenza. LPA observed four (4) out of five (5) files missing an application or personnel record.

There is at least one (1) staff member present with current CPR/First-Aid that expires 08/14/2027. Director Cyndi Sherman has current Mandated Reporter Training that expires on 10/23/2027.

LPA reminded the Director that Mandated Reporter training must be renewed by all staff every two (2) years. Director Sherman understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded the Director that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

Director was made aware that an 8 hour Health and Safety course that includes Nutrition education and Lead Poisoning training is required by all Directors. LPA reminded the Director to check www.emsa.ca.gov/childcare_provider/ in order to locate schedule a course that meets the requirement.

Facility representative 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.

LPA provided the Director with the following Licensing Documents:

  • LIC501 Personnel Record
  • LIC503 Health Screening
  • LIC701 Physician's Report
  • LIC702 Health History/ Parent's Report


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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398
VISIT DATE: 03/12/2026
NARRATIVE
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As a result of today’s inspection, six (6) Type B Deficiencies and two (2) Technical Violations are cited. Exit interview conducted with the Director. Report was reviewed and provided to the Director Cyndi Sherman along with appeal rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

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.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 03/12/2026 05:36 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 03/12/2026 at 04:42 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on LPA's observation, the licensee did not comply with the section cited above as sharp objects were in an unlocked storage containers in the play yard and cleaning powder was under the sink without a lock. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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3
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Director to add locks to storage that is unsafe for children. Director to provide written plan to LPA by POC due date, on how to address cleaning chemicals that are brought into the classroom for specific needs to ensure they are removed after use or placed in an inaccessible location from children.
Type B
Section Cited
CCR
101217(a)(7)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (7) Past experience, including types of employment and former employers.

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 out of 5 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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3
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Director to provide LPA with written plan on procedure for collecting this document from HR and keeping it with staff files or having a digital form accessible for review when licensing is present.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 05:36 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 03/12/2026 at 04:42 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 5 files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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2
3
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Director to collect any missing TB tests or assessment. Director to provide a written plan to LPA by POC due date, on how children's files will be verified that all documents are collected prior to enrollment.
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 out of 1 children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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3
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Director to collect written consent from authorized representative and provide LPA with proof by POC due 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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 05:36 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 03/12/2026 at 04:42 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ADDISON PENZAK JEWISH COMMUNITY CENTER
FACILITY NUMBER: 430709398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(3)(A)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations, the licensee did not comply with the section cited above in 6 out of 8 medications were expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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2
3
4
All expired medication need to be released to parents by next day that children are present. Director to provide a written plan to LPA by POC date, on how medication will be tracked to ensure it is stored and administered by manufacturer's and Doctor's directives.
Type B
Section Cited
CCR
101226(e)(3)(B)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.

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 1 out of 8 medications did not have written authorization from parent. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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3
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Director to collect written authorization for any medication stored at the facility. Director to provide LPA with a written plan by POC due date on how medication will be collected and the procedure in place to ensure written permission is on file along with written directives from Director and Parent as necessary.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Jennifer Beehler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


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