| Document Date: 2009-04-16 11:03:28
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Company Community Care Facilities / DIVISION AFFIDAVIT REGARDING CLIENT/RESIDENT CASH RESOURCES / / Currency USD / / Facility Facility Located / / Holiday Christmas / / Organization Department of State / California Health and Safety Code Chapter / Safety Code Chapter / / Product I/WE REALIZE THAT WILLFULLY SUBMITTING FALSE STATEMENTS CONSTITUTES GROUNDS FOR THE SUSPENSION / / ProvinceOrState California / /
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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION AFFIDAVIT REGARDING CLIENT/RESIDENT CASH RESOURCES