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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371273
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:07:13 PM

Document Has Been Signed on 08/23/2023 03:07 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:OUR SAVIOR'S LUTHERAN PRESCHOOLFACILITY NUMBER:
304371273
ADMINISTRATOR:RIVAS, AMYFACILITY TYPE:
830
ADDRESS:200 AVENIDA SAN PABLOTELEPHONE:
(949) 492-6165
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 8DATE:
08/23/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Amy RivasTIME COMPLETED:
03:45 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
On 08/23/2023 Licensing Program Analyst (LPA), A. Bootorabi conducted an on site visit for the purpose of a 1 year required inspection. LPA and Director Amy R. toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. Upon arrival, an Entrance Checklist (LIC 125) was provided to the director.
Infant Classroom #1: 2 Infants and 1 Teacher (room 304)
Infant Classroom #2: 6 Infants and 2 Teachers (room 305)

During the inspection, it was determined the facility is operating within its licensed capacity and within compliance with staffing ratios. Facility hours were confirmed with the director. The director confirmed hours are 7:30 a.m.- 4 p.m., Monday through Friday.

The LPA and director toured the facility inside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility sketch were made off-limits by means of wall dividers between napping areas and play areas. The classrooms also had a baby safe gate at entrance doors.

Documents reviewed and to be posted in a prominent, publicly accessible area at the facility: Facility License, Waivers (if applicable), Menus, LIC 613A Personal Rights, PUB 269, PUB 393 Notification of Parent Rights, and LIC 610 Emergency Disaster Plan. Documents were posted in each classroom and visible to the public.
No menus were observed as the school does not provide meals or snacks to children. Emergency disaster plan was updated in classroom #1 but not #2 and a consultation was provided. A consultation was provided for updating licensing phone number on forms publicly posted. A consultation was also provided for for updating Earthquake preparedness form.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273
VISIT DATE: 08/23/2023
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
Documents to be reviewed during inspection: Verification of Disaster and Fire Drill, Daily Activity Schedule, Sign In/Out Sheets, and LIC 9148 Earthquake Preparedness. The facility had 4 of 4 documents available for review.

The last Fire Drill was conducted on 01/13/2023. The daily activity schedule was posted inside the classrooms . The facility is using and electronic application to sign in and out.

CLASSROOMS: Classrooms 2- 2 were toured with the director. Classrooms 2 of 2 were inspected and the activity space, and items that could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children.

Napping equipment consist of cribs. Each crib was identified with a child's name and individual sheet and mattress.
A consultation for fitted sheets.

DRINKING WATER: Drinking water was observed and readily available to children in both indoor and outdoor activity areas. Children had their own individual bottles with names labeled on them.

IDENTIFICATION AND LOCATION OF MEDICATION STORED IN THE FACILITY:The LPA observed medication being stored inside the classrooms in high rise cabinet with a closed door out of reach of children. No current medication was observed just an identification of where it would be stored. A consultation was provided for over the counter medication.

The facility does not currently provided IMS for children enrolled. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273
VISIT DATE: 08/23/2023
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
CARBON MONOXIDE – SMOKE DETECTOR – FIRE EXTINGUISHER:A functioning carbon monoxide detector alarm was tested by the director during today’s visit and were observed to be functioning. A fire extinguisher was observed in classroom 1 and was last serviced in August 2022.

OUTDOOR ACTIVITY SPACE: The surface of the outdoor activity space was observed to be maintained in a safe condition for activities. The surface of the outdoor activity space was observed to be free of hazards including, but not limited to, holes, broken glass, and other debris.
There is no cushion material or large structures in the infant play yard. The children play in an enclosed grass area shaded by a large tree. Teachers were observed taking out small slides, toddler cars, and toddler size climbing structures. There are no bodies of water present at the facility. The facility’s outdoor grounds are safe, sanitary, and in good repair. LPA observed infants being placed in 4 seater strollers, pushed to the infant yard by walking through the centers parking area. Children were buckled in by staff in the 4 seater stroller.

PERSONNEL RECORDS 10:05am:The LPA requested to review staff records of adults working directly with children. The following documents were requested for review exemptions or exemptions, Staff Qualifications, Immunization Records, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to report Child Abuse, 1 CPR First Aid Certification of staff present at the facility at all times, TB clearance, and a Mandated Reporter Training Certificate.
The facility had one separate file for each staff member. The files reviewed during today’s visit were observed to be completed. There is at least one staff certified in CPR & First Aide.1 staff did not have a current Mandated Reporter Training were not updated at this time.

A consultation was provided for fully qualified teacher, teacher files and staff documentation.
A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee [or 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 the 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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273
VISIT DATE: 08/23/2023
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
The 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 the 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.

Children’s Records Reviewed The LPA requested complete children’s records of 3 children enrolled in the program. Children's records were reviewed, and there was a separate, complete, and current record for each child. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identification, Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. The children’s records were not complete currently. A consultation was provided. Review ended at 11:33 am
Files were not completed and a consultation was provided.
Child Care Licensing Program Webinars: The Child Care Licensing Program is pleased to continue offering webinars to share important information with the childcare licensing community in 2023.
2023 Webinar Schedule
• Tuesday, September 26, 2023, 6:00 p.m.
• Tuesday, December 12, 2023, 6:00 p.m.
To register for webinars, see Provider Information Notice (PIN), PIN 22-30-CCP.

The facility representative] was informed of the www.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.

Safe Sleep: LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed director 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.
A consultation was provided for sheets.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 23
Document Has Been Signed on 08/23/2023 03:07 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 08/23/2023 at 02:12 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above
by means of having incomplete staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
1
2
3
4
The director stated that she will ensure they are completed moving forward prior to the year begining.
Type B
Section Cited
CCR
101217(b)(3)(B)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 101170: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 101170(e).

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 means of not having a staff member associated to the facility but having a fax proof of attempt submission
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
1
2
3
4
Proof of addition will be sent over today to LPA.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 5 of 23
Document Has Been Signed on 08/23/2023 03:07 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 08/23/2023 at 02:12 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by means of missing training for one staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
1
2
3
4
The director stated will have the certificate available today or tomorrow. Proof of completion will be emailed to LPA
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having a complete child(ren) records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
1
2
3
4
Director stated she will work on it today and tomorrow. A statement when completed will be sent to LPA via email.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 6 of 23
Document Has Been Signed on 08/23/2023 03:07 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 08/23/2023 at 02:12 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on director interview and record review, the licensee did not comply with the section cited above by means of not having this form completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
1
2
3
4
Once the director receives the regulations she will update the form moving forward.
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having a completed or updated LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
1
2
3
4
The director stated she will be having parent complete the forms and update them quarterly.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 7 of 23
Document Has Been Signed on 08/23/2023 03:07 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 08/23/2023 at 02:12 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101427(b)(1)
Infant Care Food Services
(b) There shall be an individual feeding plan for each infant. (1) The plan shall be completed and available for use prior to the infant's first day at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, director interview interview and record review, the licensee did not comply with the section cited above by means of not having a compelted plan for each child enrolled which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
1
2
3
4
Director will meet with parents and update form.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 8 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 304371273
VISIT DATE: 08/23/2023
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
The facility did not meet the California Code of Regulations, Title 22 Division 12, and regulations not met were observed, discussed, and cited at the time of the visit.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 101217(a), 101221(a), 1596.8662(b)(1), 101221(a), 101419.2(a) , 101419.2(b)(2, 101427(b)(1))

Exit interview conducted and report was reviewed with the director Amy R

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the regional manager at the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817.


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/inspection-process

End of Report
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 23 of 23