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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416386
Report Date: 09/22/2025
Date Signed: 09/24/2025 05:18:38 PM

Document Has Been Signed on 09/24/2025 05:18 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PIMSAKUL, MATHWEE & KENDRAFACILITY NUMBER:
434416386
ADMINISTRATOR/
DIRECTOR:		PIMSAKUL, MATHWEE & KENDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
4087310417
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
09/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Mathwee & Kendra PimsakulTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On 09/22/205, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced annual/random inspection. LPA was granted access to the home by Licensee, Mathwee Pimsakul and explained the nature of today’s inspection. Present in the home was licensee and eight children including 3 infants and 5 preschool children. Upon arrival, children were observed to be napping or being assisted to sleep. Licensee, Kendra Pimsakul arrived at 1:30pm; within a few minutes of LPA's arrival. Licensee is not operating within the ratio and capacity requirements of the license. LPA explained the ratio requirements when only one Licensee is present with children. Days and hours of operation are Monday to Friday, 7:00 am to 6:00 pm. LPA observed all required posted materials near the front entrance to the home. LPA provided Licensee with a copy on the Entrance Checklist for Family Child Care Homes (LIC 126) during today's inspection. The home is single story with 5 bedrooms and 3 bathrooms. Two adults and four minor children reside in the home. Licensees provide respite care and are a Santa Clara County Resource Family (# 999637RFA). Licensees currently do not have foster care children living in the home.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children indoors and outdoors. The home has central heating/cooling and ventilation for comfort of children. LPA observed a fireplace that is barricaded with a child gate in the living room. Off limit areas inside the home: attached garage. LPA observed 3 infants and one preschool child sleeping inside cribs in different bedrooms. Infants were observed to be placed to sleep in sleep sacks and preschool child inside the crib was observed to be placed to sleep with a blanket. Doors to all rooms that the children were napping in were observed to be closed. LPA reminded licensee that if an infant is sleeping in a separate room from where the provider is stationed the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door. No loose articles including sleep sacks are allowed inside the crib. LPA observed disinfecting sprays, disinfecting wipes and hydrogen peroxide within reach of children in the bathrooms and outdoor area. LPA observed that the kitchen scissors were accessible to children. Rooms, bathrooms and passages were observed to be cluttered with clothing items. Licensee stated that the home is cleaned by a cleaning service twice a week.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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

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

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

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

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

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

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

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

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

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

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

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386
VISIT DATE: 09/22/2025
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LPA observed a fire extinguisher that was last serviced on 07/29/2024 and working smoke and carbon monoxide detector. LPA reminded licensee that the fire extinguisher needs to be serviced once every 12 months and service tag maintained for review. Licensees have one pet dog. Licensees state that they do not have any firearms. Licensees understand that smoking is prohibited in the home.

The outdoor space includes a deck with stairs leading to the lower level. Both areas are on limit to children. Off limit area outdoors is storage shed and gated right side of the home. The outdoor space and play equipment were observed to be in good condition. LPA observed a large play structure with tan bark as resilient material to absorb falls. LPA observed a trampoline in the outdoor area and reminded Licensee to follow all manufacturers instructions regarding ages of children allowed on it and to place trampoline away from the fence/wall/ other items to prevent any injuries. LPA reminded Licensee to follow manufacturers age recommendations on the large play structure. LPA observed empty water tables. No bodies of water were observed. LPA observed a fire pit with burnt coal and ashes in the on limit area. Beyond the back fence of the home is a creek area. No water was observed in the creek and the back metal fence was observed to be in good condition. LPA advised Licensee to fix any tree roots that pose a tripping hazard. Backyard is fenced and both sides of the home are gated. Shade is provided by canopies. LPA observed broken plastic bits on the left side and a rake within reach of children.

Bathroom used by children was in operating condition. Toilets and faucet are clean and operable. LPA reminded applicant that all shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/removers must be placed inaccessible to the children.

Drinking water is readily available for children in the home via individual water bottles and refilled using filtered or store bought water based on parent preference. Licensee states that she provides meals and snacks to the children in care. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated.

Licensee states that a child will be isolated in one bedroom if necessary due to illness or communicable disease until parent pick up. Licensee updated the children's roster with information of one missing child during today's inspection. LPA reviewed a Fire/Disaster drill log during today's inspection. Fire/disaster drill was last conducted on 06/21/2025.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386
VISIT DATE: 09/22/2025
NARRATIVE
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Eight children’s files were reviewed during today's inspection and found to be current and up to date. Licensee stated that she understands that she is required to check on infants but was not aware that she needed to conduct sleep checks every 15 minute for all infants and maintain documentation for review. LPA provided Licensee with a copy of PIN 20-24-CCP and sample 15- minute sleeping infant check form. Licensee states that she has liability insurance for the day care and LPA observed a current policy.

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.

LPA reviewed both Licensees files. Licensees have current Pediatric CPR/First Aid certifications. Licensees do not have current Mandated Reporter training's . Licensee understands the training is mandatory to all Licensees and adults in the home in contact will children and requires renewal every two years. Training website: www.mandatedreporterca.com. Licensee, Mathwee Pimsakul to submit proof of measles immunization to LPA by 10/06/2025.

Licensees were reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Supervision of children was discussed with Licensees, and they understand that they or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. LPA discussed the requirement for Licensees to be present at the facility 80 percent of the hours the facility is in operation and that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. Licensees understand their capacity options and understand that they cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensees understand in absence of a helper their license capacity is reduced to 8 and ratio (age of the children) must be observed.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386
VISIT DATE: 09/22/2025
NARRATIVE
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LPA discussed "zero tolerance" related regulations which includes the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Licensee is encouraged to visit the Department’s website at https://cdss.ca.gov/inforesources/child-care-licensing to access general updates, resources for providers, regulations, adoptions of new laws, pay annual fees etc.

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. LPA observed that an epinephrine auto injector for child, C8 was not in the original container and did not have a consent form. LPA provided Licensee with a copy of PIN 22-02-CCP and advised Licensee to submit a IMS plan to LPA by 10/06/2025.

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/.

Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping. Licensee, Kendra Pimsakul 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. During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Five Type B deficiencies and one technical violation were cited today. Appeal rights were printed and provided to Licensee. Exit interview conducted and report was reviewed with Licensee, Kendra Pimsakul.

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. Regular updates for licensed providers will be communicated via Provider Information Notice (PIN).
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/24/2025 05:18 PM - It Cannot Be Edited


Created By: Farida Raja On 09/22/2025 at 04:48 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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed 3 infants and one preschool child sleeping inside cribs in different bedrooms. Infants were observed to be placed to sleep in sleep sacks.
POC Due Date: 09/29/2025
Plan of Correction
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2
3
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Licensee to submit a written plan stating understanding of safe sleep regulations to LPA by 09/29/2025.
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed 3 infants and one preschool child sleeping inside cribs in different bedrooms. Doors to all rooms that the children were napping in were observed to be closed.
POC Due Date: 09/29/2025
Plan of Correction
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2
3
4
Licensee to submit a written plan stating understanding of safe sleep regulations to LPA by 09/29/2025.
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:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/24/2025 05:18 PM - It Cannot Be Edited


Created By: Farida Raja On 09/22/2025 at 04:48 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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on observation, interview and record review, both licensees did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Both Licensees are missing current Mandated Reporter Training's.
POC Due Date: 10/06/2025
Plan of Correction
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Licensees to complete the training and submit certificate of completion to LPA by 10/06/2025.
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
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3
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Based on observation, interview and record review, the licensee did not comply with the section cited above for 3 infants in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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3
4
Licensee to conduct 15 minute sleep checks for 3 infants and submit proof to LPA by plan of correction date of 10/06/2025.
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:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/24/2025 05:18 PM - It Cannot Be Edited


Created By: Farida Raja On 09/22/2025 at 04:48 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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA observed disinfecting sprays, disinfecting wipes and hydrogen peroxide within reach of children in the bathrooms and outdoor area. LPA observed that the kitchen scissors were accessible to children. Rooms, bathrooms and passages were observed to be cluttered with clothing items. In the outdoor area, LPA observed broken plastic bits on the left side and a rake within reach of children. LPA observed that an epinephrine auto injector for child, C8 was not in the original container and did not have a consent form.
POC Due Date: 09/29/2025
Plan of Correction
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2
3
4
Licensee to submit picture proof and a plan of correction for all items mentioned in the deficienct practice statement to LPA by 09/29/2025.
Section Cited
Deficient Practice Statement
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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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
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