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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801482
Report Date: 04/21/2025
Date Signed: 04/22/2025 07:02:59 AM

Document Has Been Signed on 04/22/2025 07:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VIA ESMERALDA L.L.C.FACILITY NUMBER:
565801482
ADMINISTRATOR/
DIRECTOR:		ESMERALDA OCAMPO-NUNEZFACILITY TYPE:
740
ADDRESS:3521 EAST ELMA ST.TELEPHONE:
(805) 216-6195
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
04/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Esmeralda Ocampo-NunezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:45 A.M. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit.

At 11:00 A.M. LPA and licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 03/10/2025. Between 12:20 P.M. and 12:25 P.M. smoke detectors and carbon monoxide detectors units in each room, living room and kitchen were tested and functioned properly. The facility converted the garage into an ADU (accessory dwelling unit). ADU has a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility.



BEDROOMS: There are three double occupancy resident bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff.

BATHROOMS: There are three bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and slip-resistant mats and surfaces. Between 11:07 A.M. and 11:23 A.M. hot water temperature measured between 105* - 120 *F which was within the required range.

Continued on LIC 809

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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 9
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 04/22/2025 07:02 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/21/2025 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a planter blocking an side gate used as an emergency exit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Licensee will remove planter from in front the side gate and ensure that staff will supervise residents as need it.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/22/2025 07:02 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/21/2025 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a staff member without a health screening form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee agreed to send Staff 1 to a provider and get LIC 501 complete before 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 07:02 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/21/2025 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a valid CRP/1st aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will renew CPR certificate and send proof to LPA before POC due date.
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having two (2) residents in care missing their Personal Rights form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will reach out to responsible parties and get the LIC 613 for filled out and signed before 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 07:02 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/21/2025 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having one (1) resident's admission agreement missing essential information and signatures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will contact resident's responsible party and update admission agreement before POC due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a emergency water in the facility at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will purchase a sufficient amount of water for staff and residents and submit a picture to LPA before 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/22/2025 07:02 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/21/2025 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a quarterly emergency drill documentation readily available during annual visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will conduct an in-service emergency drill and documented with all required information from CCL. Also, Licensee will read and write a statement of understanding on regulation and send it to LPA before POC due date.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482
VISIT DATE: 04/21/2025
NARRATIVE
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Continued from LIC 809-

KITCHEN: The kitchen was clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in an outdoor storage shed. At 10:35 A.M. hot water measured at 114.6 * F.

COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 71 degrees. LPA observed cameras throughout the common areas only. LPA observed a working phone available for residents use whenever needed. Facility has a small office area next to the laundry room. Facility staff and resident’s file are stored in a locked file cabinet.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture. Facility has two total gates; both were observed to be self-closing gates with one exit to have a clear passageway for emergency exit use and one to have a planter blocking a side gate used as an emergency exit. Administrator stated that facility staff uses the planter to prevent Resident #1 (R1), a wheelchair user, from leaving the facility. The LPA reminded the licensee that per RCFE regulations and fire clearance concerns the emergency exits shall not be blocked and staff shall supervise residents as need it. There were no bodies of water on the premises During the inspection the LPA observed 7 locked sheds located in the backyard, in them there was PPE supplies, pans, pots and kitchen supplies, sharps, yard tools, emergency food, party and decoration supplies, mechanical aids and devices such as crutches, walkers, and wheelchairs, folding chairs and tables, exercise equipment and extra storage room. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed outside cameras around the perimeter of the house.

Laundry room: Inside a locked room adjacent to the living area, LPA observed the washer and dryer. The laundry room leads to the ADU where cleaning supplies and disinfectants are kept stored in a locked cabinet inside.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482
VISIT DATE: 04/21/2025
NARRATIVE
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Continued from LIC 809-C

RECORD REVIEW: Between 1:34 P.M. and 2:30 P.M., staff and resident records were reviewed. The following was observed; Resident’s #1 (R1’s) needs and service plan and personal rights form (LIC 613) did not contain responsible party’s signatures. Resident’s 2 (R2’s) admission agreement was incomplete and did not have either the licensee or the responsible party’s signatures, Resident’s #3 (R3’s) was missing personal rights form (LIC 613). At 2:30 P.M. LPA reviewed staff records the following was observed: Staff #1 (S1) had an expired CPR certificate and Staff #2 (S2) was missing the health screening form.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. Facility had an updated emergency disaster plan; however, licensee was not able to provide an infection control plan. Technical violation issued. Facility has an ample supply of emergency food, however, during today’s visit, facility did not have an emergency water supply. Emergency disaster drills are conducted quarterly; however, licensee was unable to provide documentation. LPA explained licensee that based on Health and Safety regulations, documentation of the drills shall by keep in facility’s records.

MEDICATION REVIEW: Between 3:12 P.M. and 3:40 P.M. Medications for three (3) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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