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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700788
Report Date: 09/10/2026
Date Signed: 09/10/2026 06:52:46 PM

Document Has Been Signed on 09/10/2026 06:52 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:YMCA OF METRO LA/BURBANK CDCFACILITY NUMBER:
195700788
ADMINISTRATOR/
DIRECTOR:		CLAUDIA VALDESFACILITY TYPE:
860
ADDRESS:332 SAN JOSE AVETELEPHONE:
(818) 845-8551
CITY:BURBANKSTATE: CAZIP CODE:
91502
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 26DATE:
09/10/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Claudes Valdes, DirectorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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On 09/10/2026 Licensing Program Analysts (LPA) Laticia Thompson met with (Applicant/Director).The purpose of the visit was an announced pre-licensing inspection at the facility to ensure that health, safety and personal rights as required by Title 22 and Health and Safety Regulations governing California Child Care Centers will be met. There were 26 children present during this inspection. This is an application for a Single License with a Total capacity of 88; 24 infants ages birth-24 months, 32 Toddlers 18-36 months and 32 Preschoolers ages 2 years into entry of 1st grade. The child care center will operate Monday – Friday 7:00 a.m. – 6:00 p.m. LPA toured and measured the on-limits areas. An approved fire clearance has not been received. The facility has a total of 7 classrooms. Classrooms 1 and 2 are dedicated to the infants with access to 4 sinks, 2 toilets and 2 changing tables. Classrooms 3 and 4 will be dedicated to Toddlers with access to a total of 4 sinks, 2 toilets and 2 changing tables. Classrooms 5 - 7 are dedicated to Preschoolers with access to a total of 6 sinks and 3 toilets.

Infants Indoor measurements contain a total of 988.44 square feet which will accommodate applicants request for a total of 24 infants. Infants outdoor measurements totals are 897.27 square footage which will accommodate 12 infants only.

Toddlers Indoor measurements contain a total of 1,090.66 square feet which will not accommodate applicants request of 32 toddlers.Based on today’s measurement the facility capacity limit for indoor space is 31 Toddlers. Toddler outdoor measurements

Belinda Devall
Laticia S Thompson
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
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.

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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
NARRATIVE
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Preschool Indoor measurements contain a total of 1,703.34 square feet which will accommodate applicants request of 32 Preschooler. Preschool outdoor measurements totals are 3,327.84 square footage which will accommodate 32 Preschool children infants only.

The following was observed:



Parents will enter and exit through the door next to the administrative office. Parents will sign children in and out manually on the sign in and out sheets located in their individual classrooms. There are 2 staff restrooms within the facility, 1 within the administrative office and in the kitchen.

The facility has filtered water dispensers where children can fill their personal water bottles for outdoor and indoor activities. There is/are an operable carbon monoxide detector located all classrooms. LPA observed fire extinguishers with an inspection date of 10/30/2025. LPA observed First Aid Kits with the required materials including a handheld digital thermometer.

Furniture and equipment were observed to be maintained in good condition free of sharp, loose or pointed parts. Tables and chairs were observed to meet the needs of the children. There are cots and mats for napping maintained in a safe condition. There is sufficient quantity and variety of age- appropriate play equipment in good condition. There are cubbies in all classrooms for storage of children clothing and personal belongings. The classrooms have central air for heating and cooling. The classrooms were clean in good repair. Classrooms have adequate lighting. Windows were in good repair free of chipping paint, dirt, insects, or debris. LPA observed trash cans with tight fitting lids. The facility is equipped with landline telephones service. Disinfectants, cleaning solutions, and other items that are dangerous to children are stored under the sink in classrooms with safety latches inaccessible to children. There are additional cleaning materials located in the kitchen inaccessible to children.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
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All toilets and handwashing facilities are maintained in safe and sanitary operating condition. Hot water temperature controls are maintained within regulation. Handwashing fixtures do not deliver hot water.

The licensee shall be responsible for ensuring that children with obvious symptoms of illness are not accepted. The isolation area for ill children will be located in the directors office and staff restroom. The isolation area shall be equipped with a cot for ill children and shall be supervised by staff.



The applicant was advised to develop and implement a written plan to record the administration of prescription and nonprescription medications, to inform the child's authorized representative daily when such medications have been given. Medication will be stored in the director's office and medication that requires refrigeration will be stored in the refrigerator located and the kitchen inaccessible to children.

The program provides breakfast lunch and pm snacks. The kitchen and food-preparation storage areas were observed to be clean and free of litter and rubbish. All foods or beverages that require storage at a temperature of 45 degrees will be stored in the refrigerator located in the kitchen. Menus are in writing and are posted in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

The required postings are posted in the administrative office for parents and visitors to review. The facility has a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available with contingency plans for action during fires, floods and earthquakes. LPA Thompson advised Director to complete transportation section of Emergency Disaster Plan (LIC 610)

The facility does not provide transportation. Firearms and other weapons shall not be allowed on or stored on the premises of a child care.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
NARRATIVE
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The Director stated there aren’t any firearms, weapons nor bodies of water on the premises. Smoking is prohibited on the premises of a child care center as specified in Health and Safety Code Section 1596.795(b). A baby walker shall not be allowed on the premises of a child care center in accordance with Health and Safety Code Sections 1596.846(b) and (c). Licensees shall reveal each child care center license number in all advertisements in accordance with Health and Safety Code Section 1596.861

Infants

There are 3 cribs including 1 emergency evacuation crib(s) and 2 changing tables located in the infant area. LPA advised the director cribs shall not limit the ability of staff to see the infant, LPA observed a changing tables with a padded surface no less than one-inch thick, covered with washable vinyl or plastic, raised sides at least three inches high in good repair and safe condition. Director was reminded that while in use the changing table must be placed within arm’s reach of a sink.

Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant. Bottles, dishes and containers of food brought by infants authorized representatives shall be labeled with infant’s name and current date.

There is a refrigerator for infant bottles and food located in classroom #1 with a thermostat to regulate the temperature.

LPA reviewed and provided applicant will copies and postings of Title 22 regulations related to infant safe sleep. Infant Care Center Sleeping Equipment, Staff Ratios, Infant Needs and Service Plans,
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
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LPA advised applicant of the following regarding the toddler Program:

101216.4(a)(1) Preschool Program with Toddler Component A child who is between 18 months and 36 months of age may participate in the toddler program with written permission from the child's authorized representative. No child in the toddler program shall be placed in the preschool program before the age of 30 months without written permission from the child's authorized representative.

101417(a)(1) Toddler Component in an Infant Care Center. The infant care center shall obtain written permission from the child's authorized representative for the placement of the child in the toddler program.

Outdoor

The entire outdoor activity grounds are enclosed by a fence to protect children and to keep them in the outdoor activity area. The fence is at least four feet high. Play equipment and materials used by children are age-appropriate. Areas around and under climbing equipment, swings, slides and other similar equipment has artificial grass for cushioning to prevent injury from falls. The outdoor activity space was observed and maintained in good condition LPA did not observe any equipment or hazards in the outdoor activity area. There is adequate shade and benches for resting in the outdoor activity area. Applicant was advised to inspect sandboxes daily to ensure areas are free of any hazardous foreign material. LPA did not observe any bodies of water.

The following items were discussed:



The director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Child Care Center. 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.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA reviewed with [applicant, licensee, or facility representative] the LIC 311A, Records to be Maintained at the Facility, for child’s records, personnel records, administrative records, and documents to be posted. Entrance Checklist was provided to the applicant.

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 discussed the safe sleep regulations with [applicant, licensee, or 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 [applicant, licensee, or facility representative] of the importance of checking for and removing 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.

Licensee was informed of the MyChildCarePlan.org site, 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.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
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During todays inspection LPA's observed 2 Adult Staff, Daisy Beltran and Lorena Castro whom did not complete a Criminal Record Clearance/Criminal Record Exemption and/or Criminal Record Transfer prior to working, residing, or volunteering at a License Facility. Title 22 California code of Regulation section 101170(e)(1) Criminal Record Clearance. On todays date Licensee was able to associate the criminal record clearance for Lorena Castro to the facility license. Daisy Beltran was sent home pending criminal record clearance approval.

Based on today's observation a Type A violation and civil penalties are being issued (see LIC 809D)

LPA Thompson informed Claudia Valdes, Director that this report dated 09/10/2026 documents 1 Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety or personal rights of children in care.

LPA Thompson informed the Director to provide a copy of this licensing report dated 09/10/2026 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The facility is operating under an approved Emergency Approval to Operate (EAO) and has agreed to maintain and operate the facility in accordance with the laws and regulations governing the licensure.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788
VISIT DATE: 09/10/2026
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The following corrections are needed before licensure will be considered;
  • Waiver requesting Alternate usage of Toddler and Infant outdoor Activity Space.
  • Install Gate around Outdoor Activity Area.
  • Toddler and Preschool rugs are in need of cleaning.
  • Relocate changing tables in an area within arms reach of a sink
  • Room #2 require toys that encourage auditory stimulation.
  • Post Activity Schedules in all Classrooms
  • Install additional Cribs
  • Ensure infant's bottles, dishes and containers are labled with current date.


Corrections are due by 09/30/2026

An exit interview was conducted with plan of corrected items discussed. LPA provided Director with appeal rights and a copy of this report. Final license determination will be made upon review by the Licensing Program Manager and corrections.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Laticia S Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 06:52 PM - It Cannot Be Edited


Created By: Laticia S Thompson On 09/10/2026 at 05:47 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: YMCA OF METRO LA/BURBANK CDC
FACILITY NUMBER: 195700788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
101170 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview,record review, the licensee did not comply with the section cited above in 1 staff did not have a criminal record tranfer, exemption or clearance prior to working at a licensed facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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Director stated Employee was sent home, will complete a request a criminal record clearance by 09/11/2026, Employee will not return to the faciliy until clearance has been granted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Laticia S Thompson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


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