153910093-7-26-2023-57-CC-JPEE-CU4UBH-20230726152621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 153910093
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:26:37 PM

Document Has Been Signed on 07/26/2023 03:26 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE		FACILITY NUMBER:	153910093
ADMINISTRATOR:	GOMEZ NUNEZ, BERTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 778-6903
CITY:	MCFARLAND	STATE: CA	ZIP CODE:	93250
CAPACITY:	14	CENSUS: 9	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Licensee, Bertha Gomez Nunez		TIME 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 07/26/2023, Licensing Program Analyst (LPA), Jose Penate, conducted an unannounced Annual Required Inspection and was met by Licensee, Bertha Gomez Nunez and assistants (Spanish speaking). Days and hours of operation are Monday – Saturday; 4:00AM - 4:00PM. LPA toured the home inside and outside and a census was taken. This facility is licensed as a large facility of 14, there must be an additional qualified staff person present anytime the facility goes beyond the ratio for a capacity of eight. Current facility sketch was reviewed, and Licensee confirmed that the living room, dining room, kitchen, hallway restroom, and back yard are used for providing care and are accessible to children. There is a fireplace in the home and is not used during daycare hours. There are no firearms or ammunition on the premises. During today’s inspection LPA was set to review and approve the garage converted daycare room that was recently approved by the Fire department on 7/17/23. Upon arrival LPA observed the unapproved garage converted daycare room being utilized by children and staff. LPA advised licensee that the room could not be utilized prior to licensing approving the conversion made and once approval has been made then at that point the room could be used during the hours of operation for daycare children. LPA observed all Community Care Licensing (CCL) forms required to be posted being transferred to the garage converted daycare room, LPA instructed licensee to remove forms and to transfer them back to the accessible areas that were originally approved by CCL. During inspection LPA observed a 6-inch kitchen knife on the kitchen counter in the garage converted daycare. Also, during inspection LPA observed a gas griddle with a propane attached to the grill that was not covered. LPA observed staff disconnect the propane tank from the grill and placed the items in a closed off area in the backyard where children do no have access to. LPA observed medication in the approved kitchen countertop and in the approved hallway bathroom LPA observed shampoo and conditioner (Pantene-Santique & Argan Oil products) that were available to children in care. Continued on LIC809-C

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed a kitchen knife and a gas bar b q grill with propane attached accessible to children in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Licensee removed items and placed them in secured areas where children do not have access.

Type A

Section Cited

CCR

102425(a)

Infant Safe Sleep

(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During inspeciton LPA observed licensee place an infant on a cot to sleep, licensee was utilizing a blanket and a pillow while other children were playing near and around the infant. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Licensee removed the infant from the cot after instructed by LPA and placed into playpen. LPA advised licensee that she must have equipment readily available for children in care.

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During inspection LPA observed shampoo, conditioner, medication, liquor, and cleaning product available to children in care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Licensee will remove all items from the areas discussed and will ensure to have them inaccessible to children in care.

Type B

Section Cited

CCR

102425(j)(1)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. After file review and interview licensee stated that she does not document every 15 minutes when he/she falls asleep. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	LPA left licensee with a sample of the form that is needed to be utlized daily when an infant falls asleep. Licensee will ensure to document every 15 minutes from when a infant falls asleep.

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2023 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. During inspection LPA observed adult daughter assisting with children in care. After interview with adult daughter she stated that she is not an approved assistant but that she does assist with the daycare from time to time when the other assistant is not available. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit all required documents for adult daughter to be approved by the department to assist with the children in care.

Type B

Section Cited

CCR

102416.3(a)(1)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (1) Conversion of a garage (either attached or detached) into a "child care" room. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the licensee utilize the conversion garage prior to the department approving it for the care and supervision of children. Licensee stated that she has been utilizing the garage converted daycare room since 7/18/23. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Licensee will immediatly refrain from utilizing the daycare room for children in care until she makes the changes and CCL return on another inspeciton for approval of area to be utilized.

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Licensee was unable to provide proper immunizaitons for assistant. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit documention of assistant before POC date. (8/4/23)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Licensee was unable to provide 5 children files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit child files to CCL by POC date. (8/4/23)

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2023 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)(2)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Licensee was unable to provide proof of completed form LIC9227 for infants (12 months and younger). This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will have infants representative complete LIC9227 and submit completed form to CCL by POC date of 8/4/23.

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee was unable to provide completed mandated reporter training certificate. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Licensee will complete mandated reporter training and submit certification by POC date. (8/4/23)

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: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
	VISIT DATE: 07/26/2023

NARRATIVE

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During inspection LPA observed Infant #1 being put to sleep on a cot, a blanket and pillow were used to sleep the child in care. LPA instructed to licensee that the child could not have any loose articles (blanket or pillow) and that the child must be moved into a playpen or crib while they sleep. Licensee directed staff member to gather the proper equipment for the infant in care and then transferred the infant to the playpen. LPA discussed with the licensee that all equipment for children in care should be readily available prior to the children attending the facility, due to the age of the child and other children being near or around the child this could be a danger.

During inspections and observations, LPA observed licensee’s adult daughter providing care for children in care. After discussion with adult daughter, she stated that she is not an approved assistant and that she only assist her mother with the daycare children from time to time. During records review it was determined that that adult daughter does not have required documentation and training's needed to assist during operation hours of care. LPA instructed licensee that if she is to continue to assist with day-care children she is required to complete all required training's and have documentation readily available for CCL review.

During inspection LPA Penate was unable to approve the garage converted day-care room. LPA observed that is had items (shampoo-conditioner-cleaning products-car seats-adult beverages and knives) that were reading available to children in care. Licensee does not have any child proof locks to place any items in and has not placed any child locking device to prevent entryway into main residence. LPA explained that a future visit will be made for approval of the daycare conversion made and that she is not allowed to utilize the room until approval has been made by CCL.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. The home has working telephone service and LPA confirmed the phone number is 661-778-6903.

LPA and licensee discussed Safe Sleep Regulations. LPA reminded licensee of regulation to follow with infants in care and how she is to document while they are sleeping.

(Continued on LIC809-C)

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ NUNEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 153910093
	VISIT DATE: 07/26/2023

NARRATIVE

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Provider is aware to physically check on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness, and labored breathing. During records review it was determined that licensee does not document every 15 minutes when infants sleep. Individual Infant Sleeping Plan is to be completed for each infant up to 12 months of age upon enrollment. After records review and interview, licensee stated that she has not gathered documentation for the infants in care (LIC9227). LPA discussed with licensee, Infants up to 12 months of age shall be placed on their backs for sleeping and to only placed for sleeping in playpen or crib.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were not complete with emergency information as required. Licensees Mandated Reporter Training was completed on 02/27/2021 and is currently expired, licensee was unable to present her current Mandated Reporter training. Licensee’s pediatric CPR/First Aid expires on 09/10/2024.

Incidental Medical Services (IMS) are currently not being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

Licensee is advised to make this licensing report accessible to the public and to provide copies of this licensing report and LIC809-D with Type A citation to parents/legal guardians of children in care and to parents/legal guardians of children newly enrolled at the facility during the next 12 months. Licensee is to keep verification of receipt (LIC9224) in each child's file at the facility.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies being cited (See LIC809-D).

Exit interview conducted and report was reviewed with Licensee, Bertha Gomez Nunez.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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