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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800326
Report Date: 02/04/2026
Date Signed: 02/04/2026 02:04:08 PM

Document Has Been Signed on 02/04/2026 02:04 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HOLLYWOOD LITTLE RED SCHOOLHOUSEFACILITY NUMBER:
191800326
ADMINISTRATOR/
DIRECTOR:		ILISE FAYEFACILITY TYPE:
850
ADDRESS:1233 N. MC CADDEN PLTELEPHONE:
(323) 465-1320
CITY:HOLLYWOODSTATE: CAZIP CODE:
90038
CAPACITY: 43TOTAL ENROLLED CHILDREN: 40CENSUS: 34DATE:
02/04/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Head of school, Ilise FayeTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On February 4, 2026 at 9:15 am Licensing Program Analysts (LPA) Priscilla Ochoa conducted an unannounced random annual inspection. LPA was greeted by Head of School (HOS), Ilise Faye who guided LPA on a tour of the facility. This is a preschool program that operates Monday – Friday from 8:00 am – 6:00 pm. The preschool is on the same grounds as Hollywood Schoolhouse Elementary. LPA observed that both facilities are separated. Per HOS, there are 40 preschool aged children enrolled in the program and LPA observed 34 preschool children in care along with 8 staff members.

At 9:45 am, LPA was guided on a tour of facility. Before LPA reached the preschool classrooms, LPA observed a in ground swimming pool that is located in the main courtyard of the property. LPA observed the in ground swimming pool to have a tight fitted cover from Pool Saver. LPA observed the Facility’s Director to walk over the cover to show that it does sustain the body weight of an adult and the cover is secure. LPA observed the swimming pool to be surrounded by an iron rode gate that is 60 inches tall and the access gate opens away from the pool and is self-closing with a self-latching, lockable device that is no lower than 60 inches above the ground. The vertical clearance from the bottom of the enclosure to the ground is no more than 2 inches. There are no gaps in the enclosure that could allow for a sphere of 4 inches or larger to pass through. The outside surface is free of any physical characteristics that could be used as a handhold or foothold for a child to climb over. LPA also inspected the swimming pool safety equipment that is visible from the pool and available for immediate use. LPA observed a life ring that was at least 17 inches in diameter. However, LPA and HOS could not identify that the life ring obtained an approval from the United States Coast Guard approval label.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/04/2026 02:04 PM - It Cannot Be Edited


Created By: Priscilla Ochoa On 02/04/2026 at 12:47 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(b)(3)(A)
Pool Safety
(b) A licensed daycare center with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches with a United States Coast Guard approval label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the life ring that was present at the facility did not obtain a United States Coast Guard approval label, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee will purchase a life ring with a minimum exterior diameter of 17 inches with a United States Coast Guard approval label and send proof to LPA by POC date of 02/13/2026
Type B
Section Cited
HSC
1596.814(b)(4)
Pool Safety
(b) A licensed daycare center with an in-ground swimming pool on the premises shall comply with all of the following requirements: (4) The licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the facility does not perform daily inspection of the drowning prevention safety features and safety equipment before opening the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Licensee will create a daily inspection log and start documenting the drowning prevention safety features and safety equipment before opening the facility. Licensee will send proof of documentation to LPA by POC date of 02/06/2026
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2026 02:04 PM - It Cannot Be Edited


Created By: Priscilla Ochoa On 02/04/2026 at 12:47 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 6 out of 6 staff did not obtain proof of current childcare mandated reporter training certificates, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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Licensee will ensure that S1 - S6 complete childcare mandated reporter training and provide certificates to LPA by POC date of 02/20/2026
Type B
Section Cited
CCR
101226(e)(3)(B)2
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. 2. The instructions from the child's authorized representative shall not conflict with the label directions as prescribed by the child's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 6 children obtain prescribed medication at the facility and observed that the instructions on how to administer the medication the parent provided did not match the prescription provided by the physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Licensee will obtain a new Parent Consent for Administration of Medication and Medication Chart (LIC9221) for C1 and ensure that the instructions from the child's authorized representative shall not conflict with the label directions as prescribed by the child's physician.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2026


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326
VISIT DATE: 02/04/2026
NARRATIVE
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 LPA did observe a rescue pole with a body hook that is at least 12 feet long and long enough for the facility’s pool to effectively rescue a child. LPA did not observe a Daily inspection log as the facility did not have one available. Per HOS they do have a third party that comes in to use the swimming pool, and they inspect all of the equipment. LPA explained the AB 2866 Pool Safety Requirements to HOS.

Parents enter through the front gate of the school and sign in their child through ProCare app. LPA observed barcodes for procare throughout the preschool area. When LPA was guided to the Preschool area, LPA observed the classroom and play yard to be enclosed by a iron gate, which separates the preschool and elementary school. This preschool program consists of 4 classrooms: Classroom 112: 8 children and 2 staff members, Classroom 113: 10 children and 2 staff members, Classroom 114: 9 children and 2 staff members and Classroom 115: 7 children and 2 staff members. Teacher-child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. All children were observed to be under supervision, including visual supervision. Napping equipment was observed in the form of cots that are stored in a storage room that is next to room 115. Bedding was inspected for good condition, appropriate storage, and cleanliness. Per HOS, bedding is taken home every week for washing purposes. There are age-appropriate toys and supplies for children in each classroom and are in good repair in each classroom. Each child was observed to have their own cubbie to store personal belongings. All toilets and hand washing facilities are in safe and sanitary operating condition. Drinking water is available in the form of personal water bottles that are also taken outside when needed. The facility provides additional water which is dispensed in the classroom for children in care.

The classroom furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All materials and surfaces accessible to children are toxic free.

Outdoor playground is located right in front of the classrooms and LPA inspected the equipment to be in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard.

At this time, the front office is used as an isolation area. Parents are contacted immediately. There is also a cot available if needed.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326
VISIT DATE: 02/04/2026
NARRATIVE
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The facility does provide meals for children in care. LPA reminded HOS, food that is brought from home must be labeled with the child’s name and stored properly or refrigerated. There is a kitchen on site. LPA inspected the kitchen area to ensure food is not stored near cleaning solutions. Storage areas are clean, free of litter, rubbish, and rodents/vermin. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. The facility takes measures to keep the facility free of flies, other insects, and rodents. Per HOS there are no weapons, or firearms on the premises.

The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected. The following documents were posted: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), PUB 269 Child Passenger System Poster, and Daily Schedule.

LPA observed a functioning smoke and carbon monoxide detectors in each classroom. LPA observed a fully charged fire extinguisher. The valve on the fire extinguisher pointed to the fully charged green section. Fire extinguisher was serviced on 01/05/2025. Per HOS, the extinguishers are scheduled to be serviced this month. Per Title 22, Emergency Disaster Drill must be conducted at least every 6 months. LPA observed the last Emergency Disaster Drill was conducted and documented on 10/16/2025.

LPA reviewed Sign in and out sheets to ensure each sign in and sign out is time stamped along with the person who sign in and out the child.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Child records were deemed not complete. LPA observed 1 out of 6 children obtain prescribed medication at the facility. LPA inspected the medication and medication forms such as needs and service plan and Parent Consent for Administration of Medication and Medication Chart (LIC9221). LPA observed that the instructions on how to administer the medication on LIC 9221 provided by the parent, did not match the prescription label provided by the physician. LPA took a picture of the medication label and LIC 9221 as it documents that the child did use their medication in September 2025. Per HOS the child uses the inhaler as needed and the facility follows the label directions as prescribed by the child's physician. LPA explained to HOS that it’s the responsibility of the facility to ensure that the instructions from the child's authorized representative shall not conflict with the label directions as prescribed by the child's physician. This is to ensure the health and safety of the child.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326
VISIT DATE: 02/04/2026
NARRATIVE
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Staff records were reviewed to ensure Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation. Staff records were deemed not complete. 6 out of 6 staff members did not obtain proof of current childcare mandated reporter training certificates.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a childcare facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test as specified in Health and Safety Code section 1597.16. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP.). LPA verified that the lead testing was completed in accordance to the Written Directives (Interim Licensing Standards) outlined in PIN 21-21.1-CCP. LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information) LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLYWOOD LITTLE RED SCHOOLHOUSE
FACILITY NUMBER: 191800326
VISIT DATE: 02/04/2026
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Facility representative was 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on the LPA’s observations and record review, the following deficiencies listed on the attached LIC 809D (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 and safety.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Head of School (HOS), Ilise Faye.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC809 (FAS) - (06/04)
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