GODDARD SCHOOL, THE

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA), Thompson conducted an on-site inspection for the purpose of a 3 Year Inspection. LPA and Director Wendy Simonds toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 8 preschool age children with two staff and four toddler children with one toddler option staff. Facility hours are Monday through Friday, 7:30 AM to 5:30 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is stored individually and is taken home weekly to be washed. Food is prepared on site: AM and PM snacks are provided. Food prep area observed to be clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. LPA observed the floors, equipment, and furniture to be clean and free of sharp edges. The facility has conducted an emergency drill within the past six months, last drill conducted on 12/23/2024. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Continue to page 2 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 4 FACILITY NAME: GODDARD SCHOOL, THEFACILITY NUMBER: 304371415 VISIT DATE: 01/08/2025 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Page 2 The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA reviewed four staff files during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for four staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Director possesses current American Heart Association approved child CPR/First Aid certifications, which expires 1/29/2026. Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Continue to page 3 SUPERVISORS NAME: Nguyen K Tran LICENSING EVALUATOR NAME: Dean Thompson LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receiv