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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700261
Report Date: 10/01/2026
Date Signed: 10/01/2026 01:50:53 PM

Document Has Been Signed on 10/01/2026 01:50 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:JAMES FAMILY CHILD CAREFACILITY NUMBER:
367700261
ADMINISTRATOR/
DIRECTOR:		RACHEL JAMESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 202-7857
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 30CENSUS: 8DATE:
10/01/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Rachel James, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:49 PM
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On October 1, 2026, at 10:55 A.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced annual inspection at James Family Child Care Home to assess its ability to meet compliance with California Code of Regulations (CCR) Title 22, Health, and Safety requirements. LPA met with the licensee, Rachel James. LPA Del Mundo stated the reason for the inspection and was granted access to the facility. The LPA provided copies of the LIC 126 Entrance Checklist Form. LPA conducted a tour on the day care areas. The day care takes place in the following area of the home: playroom, living room 1 and 2, bathroom, and outdoor play area. Licensing fees are current.
Licensee states the day care hours of operation are 23 hours, 7 days a week. Licensee is currently providing transportation to children in care. Licensee was made aware to have a current driver’s license, vehicle registration, and car insurance when transporting children in care. During this visit, LPA observed ten children in the facility including licensee’s two grandchildren with the licensee and one assistant providing care and supervision.
Physical Plant: The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. The smoke detector and carbon monoxide detector are in operable condition (tested at 11:30 A.M.). The facility has a 2-A:10-B:C type of fire extinguisher. However, the fire extinguisher indicated that it was empty. Licensee was advised to replace the fire extinguisher. LPA cleaning products are stored in the lower cabinet under the sink with child safety latch. Knives and other sharp items are stored in the upper cabinets. LPA also observed household medications are stored inside the upper kitchen cabinets above the refrigerator. Licensee stated that no medications are currently being provided to children in care. Licensee stated that she is providing meals and snacks to children.The facility is a two-story house. All rooms upstairs are off limits, and wooden gate was used to block the entrance upstairs. There is no fireplace in the facility. The home has central heating and air conditioning units.
Lady King
Joselito DelMundo
DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261
VISIT DATE: 10/01/2026
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LPA observed safe and age-appropriate toys, books, tables, chairs, cubbies, cribs, and other learning materials. Licensee also provides sleeping cots for children to use during nap time.
LPA observed the first aid kit box stored in the upper cabinets above the refrigerator is empty. LPA advised the licensee to purchase a first aid kit.
Bathroom: Toilet, sink and faucet were clean and operable. LPA did not observe razors and/or sharp objects, shampoos, mouthwash, medications, perfumes, air freshener, nail polish and nail remover that will pose a health and safety risk to children in care. LPA observed a step stool inside the bathroom. The cabinet has child safety latch.
Licensee stated that when a child shows signs of illness, the child is separated from other children in living room #1 of the facility.
Outdoor: The facility has no body of water on the premises. LPA did not observe body of water in the backyard. LPA observed a caterpillar tunnel, seesaw, tricycles, basketball hoop, and other toys in the backyard. The outdoor has a covered patio.
At the time of inspection, Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing on the day of the incident and/or 24 hours of incident by telephone, fax and/or in writing to the Department. Licensee is familiar with the Unusual Incident Report form, LIC624B. The report on unusual incident/injuries can also be mailed to [email protected]
Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA reviewed eight children’ss file, licensee, and the assistant’s files. Based on records review, three of the eight children’s files were missing licensing forms (LIC 627, LIC 995, and LIC 282). Licensee has current pediatric First Aid/CPR training and mandated reporter training. Assistant 1 has current mandated reporter training.Licensee and assistant have immunizations against Measles and Pertussis Licensee has TB test on file. However. Assistant #1 has no TB clearance/skin test on file. Licensee stated that assistant will take the TB test tomorrow, 10/02/2026.Per licensee, there are thirty children enrolled in the day care. Licensee was advised to update the facility roster. Licensee stated that licensee provides overnight care. LPA reviewed overnight care regulations with the licensee and discussed their plan for providing overnight care. LPA also printed and provided a copy of Title 22, Division 12, Chapter 3, Article 6 – Section 102426 (Overnight Care) to the licensee/applicant.Based on records review, the fire/earthquake drills were conducted last May 8, 2026. Licensee and other adults have received criminal record clearance.

The following was discussed with the licensee:

The licensee was reminded that 100% supervision is required at all times to children in care. The licensee

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261
VISIT DATE: 10/01/2026
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was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified.

The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category. Licensee was advised to check for fixture, furniture and equipment that have been banned or recalled by the United States Consumer Product Safety Commission.

Licensee was 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.

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.


Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: [email protected]

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261
VISIT DATE: 10/01/2026
NARRATIVE
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The licensee was informed that the mandated reporter training must be completed every 2 years and is available at www.mandatedreporterca.com. New employees shall have 90 days from date of employment to complete training as required.Prior to making alterations or additions to a family childcare home or grounds, the licensee shall notify the Department of the proposed changes, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "childcare" room; Room additions to the family childcare home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition, or construction.Lead Flyer Requirement Health and Safety Code 1596.7996 mandated that effective January 1, 2019, CCC's and FCCH's are required to provide parents and guardians of children enrolling or reenrolling in care with written information on the risks and effects of lead exposure, blood lead testing requirements and recommendations, and options for locations of affordable blood lead tests as specified. A Lead Poisoning Facts Flyer was created, in partnership with the California Department of Public Health (CDPH), to satisfy this requirement.

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 [email protected]. 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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


During the exit interview the licensee, Rachel James, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM to 5:00 PM.Type B deficiencies were cited at this time. Technical assistance is also provided during this visit.A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Rachel James.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/01/2026 01:50 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 10/01/2026 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide the LIC 627 for child 6, 7, and 8 which posed a potential risk to the Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
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2
3
4
Licensee will send signed copies of 627, 9150, and 995A for child 6, 7, and 8 to LPA.
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


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Document Has Been Signed on 10/01/2026 01:50 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 10/01/2026 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide the LIC 995 for child 7 and 8 which posed a potential risk to the Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
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2
3
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Licensee will send signed copies of LIC 995 for child 7 and 8 to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


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Document Has Been Signed on 10/01/2026 01:50 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 10/01/2026 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide the LIC 282 for child 7 and 8 which posed a potential risk to the Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
1
2
3
4
Licensee will send signed copies of LIC 282 for child 7 and 8 to LPA.
Section Cited
Deficient Practice Statement
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2
3
4
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


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Document Has Been Signed on 10/01/2026 01:50 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 10/01/2026 at 01:32 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JAMES FAMILY CHILD CARE
FACILITY NUMBER: 367700261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.45
1796.45 (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide licensee’s assistant TB clearance/skin test posed a potential risk to the Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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2
3
4
Licensee will send a copy of assistant’s TB clearance/skin test to LPA.
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


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