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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402666
Report Date: 03/17/2025
Date Signed: 04/01/2025 03:14:35 PM

Document Has Been Signed on 04/01/2025 03:14 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:FERNANDO FAMILY DAY CAREFACILITY NUMBER:
197402666
ADMINISTRATOR/
DIRECTOR:		FERNANDO, FEDRICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 717-0803
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Hanna Rahbar, AssistantTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced annual required inspection at the above facility on 3/17/2025 at 12:10 PM. Upon arrival, LPA disclosed the purpose of the inspection and met with Hanna Rahbar, Licensee’s Assistant, who guided LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes LIC 126 was provided to the Licensee’s assistant to help facilitate the inspection. Also present was another assistant, per Licensee she had an emergency and had to go out of town. Licensee was not present during inspection. There were (nine) 9 day-care children (4 infants) present during today’s inspection. Per Licensee’s assistant, there are currently (nine) 9 children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Fri 7:00 AM - 6:00PM. This is an amended report.**

LPA informed Licensee if they will be absent for more than 20% of their operating hours for that day, they must close. Licensee is not allowed to leave staff in charge of the day-care will she is absent or out of town.

LPA toured the home inside and outside. This is a two-story home which consists of 5 bedrooms, 3 bathrooms, kitchen, den, dining room, living room, attached garage, laundry room, front yard and backyard (fenced).



Per Licensee, areas off limits to children and parents include: The 2nd floor, all 5 bedrooms, 4 bathrooms, laundry room, attached garage, front yard, part of the backyard.

Per Licensee, areas that are accessible to children include: Living room, den (day-care room), bathroom, dining room, living room and part of the backyard. The bathroom that children use is located to the right of the front door and was observed to be clean and free of hazards.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.
Page 1.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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 13
Document is an Amendment of Original Document on 04/01/2025 03:06 PM


Created By: Tatiana Bickham On 03/17/2025 at 02:06 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

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 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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LPA observed staff is finger print cleared. No deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 03/17/2025 03:07 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 03/17/2025 at 02:06 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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee shall provided proof of working smoke and carbon monoxide detector by date listed above.
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee shall conduct a fire and safety drill and provide a copy of the log to LPA by date listed above.
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 03/17/2025 03:07 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 03/17/2025 at 02:06 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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee will submit a statement stating she understands if she will be absent for more than 20% of her operating hours she must close the day-care. Licensee can not leave staff in charge while she is out of town.
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 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee and 2 assistants shall provide proof of completed Mandated Reporter Training by the date listed above.
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 03/17/2025 03:07 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 03/17/2025 at 02:06 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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee and two assistants shall provided proof of the above immunization's as well as a TB clearance by the date listed above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 13
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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 03/17/2025
NARRATIVE
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Individuals residing in the home have been discussed and noted. At 12:30 PM LPA observed one staff present did not have a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted in May 2024.

At 1:00 PM Smoke and carbon monoxide detectors were observed, tested and found to be not operable. Fire extinguisher indicated fully charged and but was not purchased/serviced within the year. The home maintains telephone service via and cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. Fireplace is screened to prevent access by children. LPA observed one gate that the staff use between the off-limits areas and the stairs, LPA advised another gate to be purchased. LPA observed that detergents, cleaning compounds and medication are stored in inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in dining room, away from the other children. Per Licensee assistant there are no firearms or weapons stored in the home. LPA informed Licensee, kitchen cabinets need to have safety locks, LPA observed a drawer with knives accessible to children in care.

Infant Care: Currently licensee cares for 4 infants. LPA observed 1 play yards visible in the living room. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the cribs/play yards. There are currently no infants with pacifiers. Per licensee assistant wet or soiled sheets are immediately removed. Each infant has their own play yard/ mat and bedding. Bedding is washed weekly. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following sleep supervision plan for infants: Stay in the room while the

Page 2.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 10 of 13
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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 03/17/2025
NARRATIVE
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infants are sleeping. LPA informed Licensee 15-minute sleep documentation must be completed for each infant 0-24 months, LPA provided a copy of the safe sleep log.

Overnight Care: Per Licensee assistant, no overnight care is provided.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There is a pool located in the backyard. There is an iron gate that goes from the side of the home to the fence that opens towards the body of water and is 5ft high, self-latching and self-closing and there is another mesh fence that goes around the rest of the pool making it inaccessible to children in care. The mesh fence is at least 5ft high, opens away from the body of water and is self-latching and self-closing. Licensee does not have a rescue pole with a body hook, life ring with a minimum exterior diameter of 17 inches, or a safety cover or pool alarm. LPA provided a copy of the pool regulation to the Licensee assistant.



Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months)

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

LPA Amended Report. Previously LPA observed during file review once staff was not finger print cleared, LPA was not informed the staff changed their name. LPA observed a fingerprint clearance for the staff with their previous name, not their current name.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from
Page 3.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 11 of 13
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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 03/17/2025
NARRATIVE
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corporal and/or unusual punishment.
Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. LPA also informed licensee 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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.



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

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per
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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 12 of 13
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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 03/17/2025
NARRATIVE
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violation will be assessed. The Licensee was made aware they may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. Exit interview was conducted with Licensee via telephone and with staff Dhanusika Abeysekara Wana.

During the exit interview, the LICENSEE assistant, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on the LPA’s observations and records 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 & safety.

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.

Page 5.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 13 of 13