102416.2 Reporting Requirements (a)The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm).
Licensee agrees to submit the completed LIC624 via email to [email protected] Based on information gathered, Licensee did not report an ususual incident that ocurred at the facility which poses a potential risk to children in care. Raul Navarro NAME OF LICENSING PROGRAM MANAGER: Suzette Ornelas NAME OF LICENSING PROGRAM ANALYST: LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026 I acknowledge receipt of this form and understand my appeal rights as explained and received.