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ADULT FAMILY HOME LICENSE
License Number: 753525
Pursuant to the laivs of the Stale of Washington and file Minimum Licensing Requirements
of the Department of Social and i lcallh Services, a license is hereby granted to
Greenhaven LLC
to conduct and maintain an Adult Family Home at 23326 97TII PL W
Cilv of EDMONDS, 98020 Snohomish County, Stale of Washington
for the care and supervision of adults as follows:
34-11our care for no more than 6 adults
This license shall be in force from the I Sth of December, 2017 subject to suspension or revocation for due cause.
Dementia Specialty, Menial licalth Specialty
Licensing Authority
NOTE: The department renewal of a license does not preclude the department from taking any action under WAC 389-76, based on inspection.
This license is nor Transferable, and is valid only for use by the corporation, partnership or individunl(s) In whom it is issued and fit (lot location above described.
Issued by Authority of Chapter RCW 70.129
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e�retaiy of State
I, KEN-1 WYNIAN, Secretary of State of the Slate of Washington and eustodian of its
seal, hereby issue this
CERTIFICATE OF FORMATION -
to
GREENHAVEN LLC
a/an WA Limited Liability Company. Charter documents are etlective on the elate
indicated below.
Date: 3/14/2017
UBI Number: 604-156-761
Given under nay hand 11)(1 Ilk: SCaI of lhC Ctutr
of Washinbton at Olyllipia, the StnlE+ (:lllital
Kim Wyman, Secrelury of Stale
I#I
Date Issued: 8/15/2017
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