<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191231782
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:39:41 PM

Document Has Been Signed on 11/15/2024 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PARRA FAMILY DAY CAREFACILITY NUMBER:
191231782
ADMINISTRATOR/
DIRECTOR:
PARRA,MARGARITA, PARRA MAXFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 891-7358
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Licensees, Max and Margarita ParraTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
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
Licensing Program Analyst (LPA) Roberto Luque Avila and Licensing Program Manager (LPM) Rita Ramos conducted an unannounced annual inspection to the above facility on 11/15/2024. LPA and LPM arrived at the facility at 12:35PM, identified self and met with Licensees Max Parra and Margarita Parra, who guided LPA and LPM on a tour of the facility. LPA provided Licensee with a copy of the LIC 126 Entrance Checklist to help facilitate the inspection. LPA and LPM observed 4 children with both Licensees upon arrival. Per Licensee Margarita Parra, operation hours are 6AM to 6PM. There are 13 children that are currently enrolled. Later during the visit, at approximately 2:12PM, 4 additional children arrived to the facility. Per Child #5, Licensee, Max Parra provides pick-up from school. The Licensees were observed to be operating within the license capacity limitations. This inspection was conducted in English and Spanish.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, front yard and backyard (fenced). The children use the bathroom in the hallway. The restroom that children use was observed to be safe and sanitary. LPA and LPM did not observed a fireplace in the home. Per Licensee, areas off limits to children are all bedrooms and the restroom adjacent to the kitchen. The licensee provides food for children in care.

All areas identified on the facility sketch were noted to be accessible, however, during the inspection, Licensee Max Parra informed LPA and LPM that the sketch that LPA and LPM had is not current. LPA and LPM toured the areas accessible for children to use for safety, comfort, and cleanliness. LPA and LPM also inspected a restroom and 2 bedrooms that are considered off-limits during the visit. There is a telephone landline in the facility during operation hours. There is central air heating and ventilation. Safe toys, play equipment and materials were observed. Page 1 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PARRA FAMILY DAY CARE
FACILITY NUMBER: 191231782
VISIT DATE: 11/15/2024
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
32
Detergents, cleaning compounds, medications, and other items which could pose a danger to children was observed. During nap time LPA and LPM observed a lysol spray on top of a bookcase that is within arms reach of children. Licensee removed the lysol spray during visit (pictures taken).

While touring the backyard LPA and LPM observed free weights and a ladder in the area where children play. LPA and LPM advised the licensee to remove the following items. Licensee stated they will remove the free weights and ladder (pictures taken).Licensee Max Parra stated that children have not gone outside due to the weather but understands that the items need to be removed.

The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

The home has two, 2A 10BC fire extinguisher that indicates fully charged, however their is no service tag to indicate that a service was done. The fire extinguishers had been purchased 4/28/2021. Smoke and carbon monoxide detectors are located in the living room and day care room and were tested and are operable.

All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 7/25/24

Licensee states that there are no firearms stored in the home.

Licensee does care for infants at this time, Per Licensee, the infant sleep in the daycare room where they are constantly supervised. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes, however there is no record of 15-minute checks being documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age.

Page 2 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PARRA FAMILY DAY CARE
FACILITY NUMBER: 191231782
VISIT DATE: 11/15/2024
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
32
During nap time LPA and LPM observed a child (C1) sleeping on a bouncer these items are not permitted in a family child care facility. (Photo taken)

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA and LPM did not observe any children left in parked vehicles. Car seats shall only be used for transportation. LPA and LPM did not observe any children sleeping in car seats.

The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 02/01/25 . There are first aid supplies available.

LPA observed that the Licensee and assistants have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file.

The licensee does have proof of immunization against influenza, pertussis, and measles. However Licensee and (S2) do not have report of their TB Clearance available for review at the time of visit.

Children’s records were reviewed, including emergency information and were observed to be complete.

There are no pets on the premises. LPA did not observe any pools, spas, hot tubs, fish ponds, or similar bodies of water during the inspection. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

Page 3 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PARRA FAMILY DAY CARE
FACILITY NUMBER: 191231782
VISIT DATE: 11/15/2024
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
32
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

LPA advised that if a child shows signs of illness he/she/they shall be separated from other children. Per Licensee children are separated on the other side of the day care room by the book area and parents are notified to pick up their child.

When it came to discussing criminal record clearances, LPA and LPM informed Licensee Max Parra, that a letter from the Care Provider Management Bureau (CPMB) dated April 26, 2021 addressed to the facility indicates that Licensee, Max Parra was to be removed from the facility/home and any agency licensed by the Department. A Confirmation of Removal was to be provided to the Department within 5 days from the date of the letter. LPA and LPM found no record of receipt for the Confirmation of Removal. Both Licensees, Max Parra and Margarita Parra confirmed that Max Parra has been residing in the licensed family child care home after the date of the letter. Per Max Parra, they were unaware of the letter and did not receive a copy. Per Max Parra, they will contact CPMB and will remove themselves from the facility until they can obtain additional information since they believe there might be an error, however, as a precaution and to ensure compliance, they will not reside in the home. LPA and LPM obtained a signed declaration from Max Parra noting that under penalty of perjury they were unaware of the letter and will remove themselves from the facility until further notice. Per Max Parra, they will stay at another property that they own for the time being. LPA and LPM provided a copy of the letter from CPMB.

Per Licensee, Maragarita Parra, they were also unaware of the letter from CPMB and provided a signed declaration noting that they will submit an updated form to remove Max Parra from their license. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Pg. 4 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PARRA FAMILY DAY CARE
FACILITY NUMBER: 191231782
VISIT DATE: 11/15/2024
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
32
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

LPA advised the Applicant to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

Licensees were informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

The following deficiencies listed on the attached deficiency page are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.

A notice of site visit was given and must remain posted for 30 days.

During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility.

Exit interview conducted, appeal rights and report were provided with the licensee Margarita Parra. Page 5 of 5

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 11/15/2024 05:39 PM - It Cannot Be Edited


Created By: Roberto Luque Avila On 11/15/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PARRA FAMILY DAY CARE

FACILITY NUMBER: 191231782

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on[observation, interview, record review, the licensee did not comply with the section cited above due to LPA and LPM observing that Child #1 was observed sleeping in a baby bouncer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
1
2
3
4
Per Licensee, child will not be placed a bouncer to sleep and remove the bouncer from the home and will be submitted by POC due date of 11/18/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rita Ramos
LICENSING EVALUATOR NAME:Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 11/15/2024 05:39 PM - It Cannot Be Edited


Created By: Roberto Luque Avila On 11/15/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PARRA FAMILY DAY CARE

FACILITY NUMBER: 191231782

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. In the backyard LPA and LPM observed free weights and a ladder that were accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
Per Licensee the following items will be removed by the POC due date.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. The facility has two fire extinguishers that have not been serviced and were purchased 4/28/2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
Per Licensee, an appointment will be scheduled to have the fire extinguishers serviced by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rita Ramos
LICENSING EVALUATOR NAME:Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 11/15/2024 05:39 PM - It Cannot Be Edited


Created By: Roberto Luque Avila On 11/15/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PARRA FAMILY DAY CARE

FACILITY NUMBER: 191231782

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review , the licensee did not comply with the section cited above. LPA and LPM observed Lysol spray on top of a bookcase within arms reach which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee removed the lysol spray from the area making them inaccessible at the time of visit. POC cleared.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensee Margarita Parra and Staff Sylvia Parra do not have record of their TB Clearance to provide at the time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2024
Plan of Correction
1
2
3
4
Per Licensee, they will contact their medical provider to obtain copies of their TB clearance. If these records are not available they will retake their TB Clearance tests. copies will by the POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rita Ramos
LICENSING EVALUATOR NAME:Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 11/15/2024 05:39 PM - It Cannot Be Edited


Created By: Roberto Luque Avila On 11/15/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PARRA FAMILY DAY CARE

FACILITY NUMBER: 191231782

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. No record is maintained to document infants 15 min checks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
1
2
3
4
Per Licensee, will document infants sleep every 15 min and provide a copy of their log to LPA by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rita Ramos
LICENSING EVALUATOR NAME:Roberto Luque Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 9 of 9