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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412871
Report Date: 07/14/2022
Date Signed: 07/15/2022 11:47:46 AM


Document Has Been Signed on 07/15/2022 11:47 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:CREATIVE LEARNING ACADEMY, INCORPORATEDFACILITY NUMBER:
197412871
ADMINISTRATOR:MADISON & SANDERSFACILITY TYPE:
830
ADDRESS:1718 W.MARTIN LUTHER KING BLVDTELEPHONE:
(323) 294-1444
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY:14CENSUS: 8DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia Sanders, Director TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Alicia Mooberry and Austin Estrada conducted a Required Annual Inspection on this date. LPAs met with Cynthia Sanders, Director who provided a tour of the facility. LPA provided LIC 125 Entrance checklist. This is an infant program which consists of one classroom. Facility operation hours are Monday - Friday 6:30AM to 6PM. This facility also has a neighboring Preschool component, facility #1919800179 in the same building..

All areas identified on this report were inspected. Upon arrival, LPA observed 7 infants and 4 staff. All staff have obtained background clearance.

LPA observed required posted documentation which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, PUB 269- Child Passenger Restraint System, and LIC 613A- Notification of Parent’s Rights.

Facility records were reviewed for LIC 9040- Facility Roster, 9148- Earthquake Preparedness form, Daily schedule and Disaster drill log. Disaster drill was discussed. LPA reviewed Sign In/Out sheets.. All children present were signed in with date, time and full signature of person guardian.

Indoor space is physically separate from other child care component. Furniture and equipment were inspected for age appropriateness and good repair. Toys were observed to be safe, and do not have sharp points, edges, splinters and are not made of small parts that can pose a choking hazard.

LPA did not observe any baby walkers or any items that fall into that category present in the facility. LPA observed a baby swing that is in good repair. All materials and surfaces accessible to children are toxic free. Classroom was inspected to ensure that the floors have a surface that is safe and clean.

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871
VISIT DATE: 07/14/2022
NARRATIVE
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Children have their own cubby to store their belongings. Napping equipment were observed in separate storage areas. LPA observed enough cribs for each child enrolled. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. At 9:41am LPA observe loose blankets placed in each of the empty cribs, LPA provided technical assistance to staff and director and provided a copy of the PIN20-24-CCP 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 Per Director wet or soiled sheets are changed as needed throughout the day. Each infant has their own crib and bedding. LPA observed that infant changing tables have a padded surface no less than one-inch-thick and are covered with washable vinyl or plastic and attached sink with running water. The infant changing tables have raised sides that are at least 3 inches high. Toilet training is not offered at this program.

Telephone service, heating, lighting and ventilation (fans) were evaluated and are in operating condition. Disinfectants, cleaning solutions, and other items that are dangerous to children, were observed to be inaccessible. According to the Director, medication is only administered to a child when accompanied with a doctor's note and is stored in the child's classroom inaccessible to children with the child’s name and date. Director states that there are no poisons stored at the facility and understands that storage areas for poisons must be locked with a key or combination lock. Facility has one or more carbon monoxide detectors that meet statutory requirements.

Menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. The facility provides AM snack, lunch and PM snack for children who eat table food. Bottles, dishes, and containers of food brought by the infant’s authorized representative are labeled with infant’s name and the current date.

All food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins have tight-fitting covers that are kept on, and in good repair. All foods/beverages are stored in covered containers at 45˚ (F) or less. LPA observed two (2) expired Milk gallons with a past due use by date of 7/11/22 which poses a potential risk of children in care. The expired milk was immediately removed from the refrigerator.

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871
VISIT DATE: 07/14/2022
NARRATIVE
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Outdoor space is physically separate from other child care components. Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is made of artificial grass on top of cushioned material.

The outdoor area has adequate shade. LPA did not observe any bodies of water or firearms during this visit.

Children’s records were reviewed at for Immunization Records, Licensing Form (LIC) 627- Consent for Medical Treatment, LIC 700- Identification and Emergency information, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, Need and Service Plan, LIC 9227 Infant Sleep Plan, 15 minute check document and signed Admissions Agreement. Forms were discussed. Record review revealed the following items were missing from the children’s files which poses a potential risk for the health and safety of children in care.:


-15 minute Infant sleep logs missing from 5 out of 5 children’s records
-LIC 9227 Infant Sleep Plan missing from 1 out of 5 children’s files reviewed.
-LIC 700 Missing from 1 out of 5 files reviewed

Staff records were reviewed at for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 503- Health Screening, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit and current Mandated Reporter Training Certificate. Forms were discussed.
Staff files were missing the following documents:
-Immunizations missing from 2 out of 5 files reviewed
-Mandated Reporter was expired for 5 out of 5 files reviewed
-Pediatric First Aid/CPR is expired for 5 out of 5 records reviewed

LPA provided a copy of PUB 269 and discussed with Director updating licensing forms to include the correct Regional Office information.
COVID-19 guidelines and recommendations were discussed. Please visit the local department of health website for the most up to date information.
Director was reminded to ensure the licensing fees are paid.
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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871
VISIT DATE: 07/14/2022
NARRATIVE
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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

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.

Facility representative was reminded that all adults 18 and older, 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.

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-and-resources/safe-sleep as an additional resource. LPA also informed facility representative 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.

Based on the LPA's observations and records review deficiencies will be cited today 7/14/22.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility Representative Cynthia Sanders. Appeal rights were discussed and a copy provided

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 07/15/2022 11:47 AM - 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101439.1(f)
Infant Care Center Sleeping Equipment
(f) Cribs shall be free from all loose articles and objects, including blankets and pillows.

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 infant cribs had baby blankets, posing a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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Blankets were removed from the cribs. Deficiency corrected during inspection
Type B
Section Cited
CCR
101238.2(d)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained:

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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Wuill be covered and a picture sent to LPA by 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.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 07/15/2022 11:47 AM - 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217
Criminal Record Clearance
101217 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: (11) A health screening as specified in Section 101216(g) (12) Tuberculosis test documents as specified in Section 101216(g).

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 in 5 out of 5 staff files that were reviewed were missing proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Per licensee, they will provide proof of the required immunization for facility staff via email by POC due date.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that 5 out of 5 staff records reviewed had expired Pediatric First Aid/CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Per Director, the staff will renew the EMSA approved Pediatric Fist Aid and CPR certification and a copy porvided to LPA via email by 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.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 07/15/2022 11:47 AM - 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Teacher Qualifications and Duties
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children's fiels reviewed did not have the required LIC 9227 Infant sleep Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Per Director Documents will be provided to LPA via emal by 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.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 07/15/2022 11:47 AM - 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CREATIVE LEARNING ACADEMY, INCORPORATED
FACILITY NUMBER: 197412871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(C)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 5 out of 5 children's files did not have the Infant Sleep log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Per Director, documentation shall be maintained in the infant’s file and be available to the Department for review to include the following: 1. Date. 2. Infant’s name. 3. Time of each 15-minute check. 4. Initials of staff person who
conducted each check. A copy of sleep log for Child #1-#5 will be provided via email to LPA by POC due date
Type B
Section Cited
CCR
101227(a)(19)
Food Services
(19) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

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 due to LPA observed two (2) expired Milk gallons with a past due/use by date of 7/11/22 which poses a potential risk of children in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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The expired milk was immediately removed from the refrigerator. Deficiency corrected during visit. Per director, they wll ensure that kithen staff will go though food inventory and discard items upon expiration.

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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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