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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494465
Report Date: 03/04/2025
Date Signed: 03/07/2025 10:01:12 AM

Document Has Been Signed on 03/07/2025 10:01 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ADOLPHUS FAMILY CHILDFACILITY NUMBER:
197494465
ADMINISTRATOR/
DIRECTOR:		IESHA ADOLPHUSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 829-6374
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 16DATE:
03/04/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Iesha AdolphusTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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On 3/04/2025, Licensing Program Analyst (LPA) Ranita Richmond and Brittany Lovest conducted an unannounced visit to the above-named home. The reason for the visit is to conduct the Required 3-year Inspection. LPA was greeted by licensee Iesha Adolphus. LPA Richmond observed 16 children, being supervised and cared for by licensee and assistant. Hours of operation are Monday through Sunday, 4:00am –11:00pm. Licensee is open for overnight and weekend care. Licensee provides meals, snacks, and water.

LPA Richmond toured the home inside and outside for a Health and Safety inspection.

LPA Richmond confirmed that the home is a single story home. The home consists of three bedrooms, two bathrooms, living room, kitchen, family room, detached garage, and fenced back yard.
The ON LIMIT AREAS are as follows: Family room, bathroom #2, and fenced back yard.

The OFF-LIMIT AREAS are as follows: kitchen, bedrooms #1, #2, and #3, and living room..

Children and parents enter through the back of the home entrance through gated back yard. Upon entrance you are in the family room. In the family room to the left is bathroom #2. Through the family room to the far left is a hallway that leads to kitchen. Staight through the kitchen is the livingroom. Inside the livingroom is the front door that leads to Hillcrest Ave. To the left of the living room is a hallway that leads to three bedrooms and a bathroom. In the hallway on the left is bathroom #1 and next to bathroom on the left is bedroom #1. On the right side of the hallway is bedrooms #2 and #3.

Licensee is aware that the children must nap and have meals in the home.

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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 10
Document Has Been Signed on 03/07/2025 10:01 AM - It Cannot Be Edited


Created By: Ranita Richmond On 03/04/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

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 LPA observed 16 children in care during annual required inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee will call for at least two children to be picked up immediately to bring licensee back into compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/07/2025 10:01 AM - It Cannot Be Edited


Created By: Ranita Richmond On 03/04/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

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
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Based on observation, the licensee did not comply with the section cited above by LPA observed disinfectant wipes and spray on bookshelf in the family room. LPA observed hygiene and beauty supplies in medicine cabinet in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will remove disinfectants from the bookshelf, hygiene and beauty supplies from the medicine cabinet in the bathroom. Licensee will house items where they are inaccessible to children in care.
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

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 LPA observed boppy inside of crib which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will house boppy and other loose items for infant care in area that is not the crib at all times
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:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/07/2025 10:01 AM - It Cannot Be Edited


Created By: Ranita Richmond On 03/04/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

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 LPA observed infant pacifier attached to a pacifier clip which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will ensure that all pacifiers used are free from attachments at all times.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

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 LPA observed mats hanging over the side of the crib and rings connected to the side of the crib which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will remove and house loose items in places that are not attached to the crib at all times.
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:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/07/2025 10:01 AM - It Cannot Be Edited


Created By: Ranita Richmond On 03/04/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

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 LPA observed infant asleep in a car seat inside of the crib which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will use car seats for purposes it was intended for at all times.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 0 out of 4 children files missing immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will request from parents all children in care immunization records and place in each child's file for review by the department.
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:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/07/2025 10:01 AM - It Cannot Be Edited


Created By: Ranita Richmond On 03/04/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
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.

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 1 children's file is missing LIC 9227 forms for children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will provide LIC 9227 forms to authorized representatives of infants 12 months and under and complete section D as necessary and file in childrens file for review by the Department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Ranita Richmond
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465
VISIT DATE: 03/04/2025
NARRATIVE
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LPA Richmond observed a fully charged 2A:10B:C Fire Extinguisher in the family room.

There are no firearms or ammunition on the premises. There are no pools, ponds or other bodies of water on the premises.

LPA Richmond observed age-appropriate toys, books and furnishings. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts.

During walkthrough LPA observed six children outside and ten children inside for a total of sixteen children in care. Licensee is operating outside of the license capacity. Type A citation issued. Licensee made calls to parents and two children where picked up at approximately 1:55pm. LPA observed disinfectant wipes and spray on top of shelf in family room and beauty and hygiene items in medicine cabinet in bathroom #1. Type B citation issued. LPA observed loose items inside of crib. Citation issued. LPA observed items attached to the side of the crib. Citation issued. LPA observed infant pacifier with clip attached. Citation issued. LPA observed infant in car seat inside of a crib asleep. Citation issued.

LPA reviewed 4 of the children’s files and observed them to be incomplete and missing immunizations. Citation issued. See LIC 809D. LPA observed in 1 of 4 files missing LIC 9227 for infant in care. Citation issued.

LPA Richmond observed the licensee has a current 1st aid/cpr completed on 12/07/23. Licensee is unable to provide a certificate of completion for mandated reporter training.



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. During file review LPA observed missing infant sleep charts. Type B citation cited. LPA provided licensee with infant sleep charts for daily completion.


Incidental Medical Services (IMS) are not currently being provided.
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465
VISIT DATE: 03/04/2025
NARRATIVE
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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.

LPA Richmond reminded Licensee of the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of 100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

LPA provided applicant with the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA Richmond gave applicant a packet of all required forms, and posters and reviewed following forms:

CHILDREN'S RECORDS REQUIREMENTS:

· LIC 700 Identification and Emergency Information


· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· LIC 9927 Individual Infant Sleeping Plan
· LIC 995A Notification of Parent’s Rights
· LIC 613A Personal Rights
· Immunization Record
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465
VISIT DATE: 03/04/2025
NARRATIVE
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FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Property Owner/Landlord Consent Form
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – must be renewed every two (2) years.

FORMS TO BE POSTED


· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster

In addition, LPA Richmond informed applicant of the following:

o There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.
o Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
o Saucer chairs, bouncers, walkers, or any similar items are prohibited.
o All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
o LPA provided and advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ADOLPHUS FAMILY CHILD
FACILITY NUMBER: 197494465
VISIT DATE: 03/04/2025
NARRATIVE
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LPA Ranita Richmond informed licensee Iesha Adolphus that this report dated 3/04/25 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Ranita Richmond informed the licensee to provide a copy of this licensing report dated 3/04/25 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Deficiencies were cited today, per Title 22 Regulations and Health and Safety Codes. See LIC 809D.

An exit interview was completed with licensee Iesha Adolphus. A copy of report and appeal rights were provided to licensee.

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

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Ranita Richmond
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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