Inspection Reports for
Vineyard Place
24325 Washington Ave, Murrieta, CA 92562, United States, CA, 92562
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
0.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 63
Capacity: 82
Deficiencies: 1
Date: Jan 9, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 07/18/2022 alleging staff not abiding by resident's care plan, restricting visitation, over-medicating a resident, and licensee not reporting an incident.
Complaint Details
The complaint investigation addressed multiple allegations: staff not following resident care plans, restricting visitation, over-medicating a resident, and failure to report an incident. The first three allegations were unsubstantiated, while the failure to report an incident was substantiated.
Findings
The investigation found the allegations that staff were not following care plans, restricting visitation, and over-medicating residents to be unsubstantiated based on interviews and record reviews. However, the allegation that the licensee failed to report an incident involving a resident's hospitalization was substantiated.
Deficiencies (1)
Failure to report an incident to The Department as required, posing a potential personal rights risk to residents.
Report Facts
Capacity: 82
Census: 63
Plan of Correction Due Date: Jan 23, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kyle Wellington | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Angela Jackson | Community Relations Director | Met with Licensing Program Analysts during the investigation |
| Arlene Crawford | Administrator | Interviewed regarding allegations and incident reporting |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 82
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-07-18 regarding resident care, food service, facility sanitation, and phone call restrictions at Vineyard Place.
Complaint Details
The complaint investigation was unsubstantiated for all allegations, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found insufficient evidence to substantiate any of the allegations, including resident developing sepsis while in care, staff serving cold food, inadequate food portions, unsanitary conditions, and restriction of phone calls. Interviews and observations supported that the facility was clean and residents were not restricted from phone calls.
Report Facts
Staff interviewed: 8
Previous staff attempted to interview: 6
Residents interviewed: 2
Facility capacity: 82
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Evaluator | Conducted the complaint investigation |
| Kyle Wellington | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Angela Jackson | Community Relations Director | Met with during investigation and provided information |
| Arlene Crawford | Administrator | Facility administrator interviewed during investigation |
| Rikesha Stamps | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 82
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-07-18 regarding staff not following resident's advanced directives, not meeting resident's toileting needs, and not keeping the facility free from odor.
Complaint Details
The complaint included allegations that staff were not following resident's advanced directives about decision-making, not meeting toileting needs, and not maintaining the facility free from odor. The investigation found no preponderance of evidence to substantiate these allegations.
Findings
The investigation involved interviews with staff, residents, and review of records. All allegations were found to be unsubstantiated due to insufficient evidence to prove violations occurred.
Report Facts
Capacity: 82
Census: 63
Staff interviewed: 8
Residents interviewed: 2
Complaint received date: Jul 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation |
| Kyle Wellington | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Jackson | Community Relations Director | Met with during investigation |
| Rikesha Stamps | Supervisor | Supervisor overseeing the investigation |
| Arlene Crawford | Administrator | Facility Administrator interviewed regarding odor allegation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 82
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility was not allowing residents to have visitors and did not have sufficient staff to meet residents' needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included denial of visitation due to COVID-19 cases and insufficient staffing to meet resident needs. Interviews and record reviews did not support these claims.
Findings
The investigation found no corroborating evidence to support the allegations. Interviews with residents, staff, and the administrator, as well as record reviews, confirmed that visitation was not denied and staffing levels were sufficient to meet residents' needs. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 82
Census: 63
Staffing per shift: 4
Staff interviewed: 1
Residents interviewed: 3
Additional residents interviewed: 2
Additional staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Evaluator | Conducted the complaint investigation |
| Kyle Wellington | Licensing Program Analyst | Conducted the complaint investigation |
| Angela Jackson | Community Relations Director | Met with Licensing Program Analysts during the investigation |
| Arlene Crawford | Administrator | Provided information regarding visitation and staffing |
| Rikesha Stamps | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 82
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-01-17 alleging staff neglect resulting in a resident sustaining a pressure injury with maggots observed on the resident on 2023-10-12.
Complaint Details
The complaint alleged staff neglect causing a resident to have maggots on a pressure injury. The allegation was investigated and found to be Unfounded based on lack of evidence and denial by hospice and wound care staff.
Findings
The investigation found no evidence to support the allegation. Hospice and wound care nurses denied the presence of maggots, and progress notes on the date of the allegation showed no unusual skin changes. The allegation was deemed Unfounded.
Report Facts
Facility capacity: 82
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Angela Jackson | Community Relations Director | Met with the Licensing Program Analyst during the visit and received the report |
| Carolyn Tuba | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 82
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint alleging staff neglect resulting in a resident sustaining a pressure injury with maggots observed on 10/12/2023.
Complaint Details
The complaint alleged staff neglect causing a resident to sustain a pressure injury with maggots present. The allegation was investigated and found to be Unfounded, meaning it was false, could not have happened, or lacked reasonable basis.
Findings
The investigation found no evidence to support the allegation. Hospice and wound care nurses denied the presence of maggots, and progress notes on the date of the allegation showed no unusual skin changes. The allegation was deemed Unfounded.
Report Facts
Facility capacity: 82
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Angela Jackson | Community Relations Director | Met with the Licensing Program Analyst during the investigation and exit interview |
| Carolyn Tuba | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 57
Capacity: 82
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
An unannounced 1-year required visit was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with no deficiencies issued. Resident and staff records were reviewed and found complete, medication administration records showed no discrepancies, and the facility environment met all required standards.
Report Facts
Residents reviewed: 5
Staff records reviewed: 5
Food supply days: 2
Food supply days: 7
Licensed bedridden capacity: 20
Bedrooms: 64
Residents out of community: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Flores | Licensing Program Analyst | Conducted the inspection and resident/staff record reviews |
| TJ Taylor | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Nikki Hultquist | Clinical Service Director | Contacted by receptionist to be informed of the inspection purpose |
Inspection Report
Census: 51
Capacity: 82
Deficiencies: 0
Date: May 1, 2025
Visit Reason
An unannounced case management incident visit was conducted to verify the whereabouts of Staff #1 and to obtain an update on the status of an internal investigation related to an alleged incident. Additionally, the visit included a follow-up on the facility's unpaid annual fees.
Findings
No deficiencies were cited during the visit. The facility paid the outstanding annual fees of $2,601.00 during the visit, and documentation was reviewed. Interviews and documentation related to the alleged incident were conducted and reviewed.
Report Facts
Outstanding balance paid: 2601
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Taylor | Executive Director | Met with Licensing Program Analyst during the visit and provided updates on the internal investigation |
Inspection Report
Census: 51
Capacity: 82
Deficiencies: 0
Date: May 1, 2025
Visit Reason
An unannounced case management incident visit was conducted to verify the whereabouts of Staff #1 and to obtain an update on the status of an internal investigation related to an alleged incident. Additionally, the visit included a follow-up on the facility's unpaid annual fees.
Findings
The Licensing Program Analyst conducted interviews, reviewed documentation related to the alleged incident, and confirmed that the facility paid the outstanding annual fees of $2,601.00 during the visit. No deficiencies were cited during this inspection.
Report Facts
Outstanding annual fees paid: 2601
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Taylor | Executive Director | Met during the visit and provided updates on the internal investigation |
| Javina George | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 53
Capacity: 82
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced visit to perform a required annual inspection of the facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. The facility environment, client and employee records, medication storage, and safety measures were all reviewed and found satisfactory.
Report Facts
Client records reviewed: 10
Employee records reviewed: 7
Facility capacity: 82
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Taylor | Administrator | Met with Licensing Program Analysts during inspection |
| Arlene Crawford | Administrator/Director | Named as facility administrator/director |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
| Armando Perez | Licensing Program Analyst | Conducted the inspection |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Annual Inspection
Census: 53
Capacity: 82
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced visit to perform a required annual inspection of the facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. The facility environment, client and employee records, medication storage, and safety measures were all reviewed and found satisfactory.
Report Facts
Client records reviewed: 10
Employee records reviewed: 7
Facility bedrooms: 64
Food supply duration: 7
Food supply duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Taylor Jr | Administrator | Met with Licensing Program Analysts during inspection |
| Armando Perez | Licensing Evaluator | Conducted the inspection |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
The visit was conducted to investigate a complaint received on 2022-08-03 alleging that a resident's medical needs were not being met, specifically that Resident Number 1 had not seen a physician since initial hospitalization and had not received medical attention.
Complaint Details
The complaint alleged that a resident's medical needs were not being met, including lack of physician visits and medical attention. The investigation found the resident was receiving Hospice care and medical attention as needed, leading to the complaint being classified as unfounded.
Findings
The investigation, which included staff and resident interviews, record reviews, and observations, found that the resident receives Hospice services and medical attention two to three times a week. The evidence did not support the allegation, and the complaint was deemed unfounded.
Report Facts
Capacity: 82
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ivy Villapando | Clinical Services Director | Met with the evaluator during the investigation |
| Thomas Taylor | Executive Director | Received a copy of the report during the exit interview |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that a resident's medical needs were not being met, specifically that Resident Number 1 had not seen a physician since initial hospitalization and had not received medical attention.
Complaint Details
The complaint alleged that a resident's medical needs were not being met, including lack of physician visits and medical attention. The allegation was investigated and found to be unfounded based on interviews, observations, and record reviews.
Findings
The investigation found that the resident receives Hospice services and is seen by a Hospice Nurse several times a week, with the attending physician responsible for medical care. Staff interviews and record reviews did not corroborate the allegation, and the complaint was deemed unfounded.
Report Facts
Capacity: 82
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ivy Villapando | Clinical Services Director | Met with the Licensing Program Analyst during the investigation |
| Thomas Taylor | Executive Director | Received a copy of the report during the exit interview |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 82
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not properly trained on resident transfers, and that the facility was in disrepair, unsanitary, and malodorous.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations regarding staff training, facility disrepair, unsanitary conditions, and malodor.
Findings
Based on observations, interviews, and records review, the allegations were found to be unsubstantiated. Staff training was verified, the facility was functional despite minor issues, and the malodor was attributed to resident incontinence with cleaning efforts in place.
Report Facts
Capacity: 82
Census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nieves Villapando | Clinical Service Director | Met with Licensing Program Analyst during investigation and exit interview |
| Arlene Crawford | Executive Director | Provided information regarding staff training and assessments |
| George Uhila | Maintenance Director | Interviewed regarding facility cleaning and malodor |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 82
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not properly trained on resident transfers, and that the facility was in disrepair, unsanitary, and malodorous.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper staff training on resident transfers, facility disrepair, unsanitary conditions, and malodorous environment. Evidence did not support these allegations.
Findings
Based on observations, interviews, and records review, the allegations were found to be unsubstantiated. Staff training was documented, facility disrepair was minimal and functional, sticky floors were due to cleaning chemicals not urine, and the urine odor was attributed to the resident population with incontinence issues and managed with cleaning efforts.
Report Facts
Facility capacity: 82
Resident census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Arlene Crawford | Executive Director | Provided information regarding resident assessments and staff training |
| Nieves Villapando | Clinical Service Director | Met with Licensing Program Analyst during investigation and received exit interview |
| George Uhila | Maintenance Director | Interviewed regarding facility cleanliness and odor |
Inspection Report
Annual Inspection
Census: 41
Capacity: 82
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An unannounced visit was conducted for an annual inspection to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control, safety, and staffing requirements. No deficiencies were cited during the inspection.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Food supply: 2
Food supply: 7
Hot water temperature: 109.2
Hot water temperature: 106.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene Crawford | Executive Director | Met with Licensing Program Analyst during inspection and assisted with the tour |
| Sara Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Tiffany Querido | Staff Development Director | Conducted the tour of the facility with Licensing Program Analyst |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 41
Capacity: 82
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Sara Martinez to evaluate compliance with regulatory requirements at Vineyard Place facility.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control, safety, staffing, medication management, and emergency preparedness requirements. No deficiencies were cited during the visit.
Report Facts
Hot water temperature in resident bathrooms: 109.2
Hot water temperature in hallway bathrooms: 106.7
Staff files reviewed: 5
Resident files reviewed: 5
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene Crawford | Executive Director | Met with Licensing Program Analyst during inspection and assisted with facility tour |
| Sara Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Tiffany Querido | Staff Development Director | Conducted the facility tour with Licensing Program Analyst |
| Joel Esquivel | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 38
Capacity: 82
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The inspection was an unannounced required annual visit with emphasis on infection control conducted on September 15, 2022.
Findings
The facility was found to have sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. There were no cases of COVID-19 at the time of inspection, and the facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
Report Facts
Number of caregivers present: 28
COVID-19 cases: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene Crawford | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection and made observations |
| Jazmond D Harris | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 38
Capacity: 82
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The inspection was an unannounced required annual visit with emphasis on infection control.
Findings
The Licensing Program Analyst observed sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
Report Facts
Caregivers present: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arlene Crawford | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection and made observations |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 45
Capacity: 82
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
Licensing Program Analyst Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.
Findings
The facility was found to have sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases, maintaining PPE supplies, and ensuring staff training in infection control.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Niedrich | Clinical Services Director | Met with Licensing Program Analyst during inspection and discussed infection control practices. |
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced annual inspection. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 82
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control.
Findings
The facility was found to have sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The designated infection control lead person effectively manages COVID-19 tracking, PPE supplies, and staff training on infection control.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Niedrich | Clinical Services Director | Met with Licensing Program Analyst during inspection and discussed infection control practices. |
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced annual inspection. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 82
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-02-17 regarding lack of supervision resulting in a resident being hit by another resident.
Complaint Details
The complaint alleged lack of supervision resulting in a resident being hit by another resident. The allegation was unsubstantiated due to insufficient evidence to prove the violation.
Findings
The investigation found that the incidents occurred in the main activity room with staff present and no injuries were sustained. Both residents involved have dementia which can cause impulsive behavior. There was insufficient evidence to substantiate the allegation of lack of supervision.
Report Facts
Capacity: 82
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Mullen | Licensing Evaluator | Conducted the complaint investigation |
| Jesse Gardner | Licensing Program Analyst | Delivered findings of the allegation |
| Arlene Crawford | Executive Director | Met with evaluators during investigation |
| Dawniesha Amaya | Administrator | Facility administrator interviewed during investigation |
| Karen Clemons | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 82
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 02/17/2021 regarding lack of supervision resulting in a resident being hit by another resident.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations did or did not occur.
Findings
The investigation found that the incidents occurred in the presence of staff and no injuries were sustained. Both residents involved have dementia which can cause impulsive behavior. There was insufficient evidence to substantiate the allegation of lack of supervision.
Report Facts
Capacity: 82
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Mullen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jesse Gardner | Licensing Program Analyst | Delivered findings of the complaint investigation |
| Arlene Crawford | Executive Director | Met with investigators during the complaint investigation |
| Dawniesha Amaya | Administrator | Facility administrator involved in interviews during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
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