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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012018
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:45:08 PM


Document Has Been Signed on 06/13/2022 03:45 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:PRECIADO CAMARENA FAMILY CHILD CAREFACILITY NUMBER:
198012018
ADMINISTRATOR:PRECIADO, SILVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 581-9254
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY:14CENSUS: 10DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Silvia Camarena Preciado, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA)Katrina Chicote conducted an Unannounced Required – 1 Year inspection to the above facility on 06/13/2022 at 12:00 PM. LPA called facility prior to entering to COVID-19 screening call. Upon arrival, LPA disclosed the purpose of the inspection and met with Licensee, Silvia Camarena Preciado, who guided the LPA on a tour of the facility. Adults in the home were discussed and all have criminal record clearance. Also present was A1, Licensee’s Assistant, who has criminal record clearance. There were 10 day care children present during today’s inspection with one napping child (C1) observed in playpen in converted garage daycare activity space. Licensee states that there are currently ten children enrolled. The children's roster was reviewed and is current. Per licensee, the facility’s hours of operation are Monday thru Friday, 9:00 AM to 6:00 PM. Emergency Disaster Plan, License, and Parents’ Rights were posted at the time of inspection. Disaster drill log was also available during today’s inspection, last disaster drill conducted on 06/13/2022.

This is a single-story home which consists of three bedrooms and two bathrooms, kitchen, living room, and attached garage converted to daycare space. Property is bottom unity of duplex property with top unit having separate address (825 E. 87th St). Areas used by the children include the converted attached garage for daycare activity space (located in the rear of the home with side entrance), Bathroom 1(located through door to left of converted daycare space) and Bedroom 1(located next to Bathroom 1) is only used as a walkway to enter rest of home, Living Room (located to the front of the home), and Dining Room (located next to Living Room). Per Licensee, areas off limits to children and parents include Bedrooms 2 and 3, Bathroom 2, and Kitchen. LPA did not observe any gate blocking access to Kitchen at time of inspection, Licensee states she supervises children when Living Room is used for nap time. LPA notified Licensee that there needs to be something making this area off limits per Title 22 Regulation requirement. Per Licensee, off limit bedrooms are closed and locked during operating hours. LPA did not observe these doors to be locked at time of inspection. LPA observed two small Yorkies and a parrot in large birdcage that was in activity space later moved to outside space. Licensee states these are all her pets in the home.
Report Continues - Page 1 of 4
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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 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: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018
VISIT DATE: 06/13/2022
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All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. LPA observed A/C wall unit in converted garage daycare activity space. There is a working telephone maintained in the home. At 12:01 PM, LPA observed converted activity space to have cubbies for children's belongings, two children's high chairs, child size tables and chairs stacked, puzzles, plastic dinosaurs and cars, and other age appropriate toys available for children in care at time of inspection. LPA observed various miscellaneous items stored against walls in of activity space such as mattresses, paint buckets, cleaning equipment. LPA observed items stacked unbalanced in activity space such as televisions, boxes, frames, and plastic bags filled with various items. LPA observed all ten children in activity space during inspection with free access to these items. At 12:01 PM, LPA observed Bathroom 1 to have operable toilet and sink with adequate hand washing supplies at time of inspection. At 12:02 PM, LPA did not observe the following were inaccessible at time of inspection: Listerine Mouthwash, three pairs of sharp scissors, multiple shaving equipment and razor refills, cleaning solutions such as Clorox, Borax and disinfectant solutions. LPA observed these items stored in Bathroom 1 with no child safety locks on any under cabinet sinks and drawers at time of inspection. At 12:04 PM, LPA observed Living Room to have couches and entertainment area. LPA observed the two small Yorkies in Living Room. LPA observed a dog pee pad with dog pee and various spots on Living Room floor with dog urination. At 12:05 PM, LPA observed Kitchen area to not have operable child safety lock under cabinet sink and observed Black Flag Ant & Roach killer being stored. Licensee states this area is off limits, LPA stated off limits areas need to be made off limits. Per Licensee, they provide food for children in care and use converted attached garage for eating.

Per Licensee, the children will have access to front yard for outdoor play. At 12:04 PM, LPA observed front yard accessible through side door in converted detached garage and walking through side yard. LPA observed side yard has various hazards such as bed frame, wooden planks and doors leaning against wall; plastic toy bin filled with toys that have debris on top and spider webs. Licensee states plastic bin will be thrown away and that side yard is only used as a walkway. LPA observed bicycles in side yard, which Licensee states is only used to store these items. LPA observed front yard has grass, concrete driveway. and adequate perimeter fencing through-out the yard.

Per Licensee, there are no weapons, firearms in the home and there are no bodies of water around the premises. LPA observation did not see any of these items around the premises.
Report Continues - Page 2 of 4
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 2 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: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018
VISIT DATE: 06/13/2022
NARRATIVE
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At 12:03 PM, LPA observed the valve on the required 2A 10BC fire extinguisher indicates fully charged with service tag dated 10/29/2021. At 12:05 PM, LPA observed the smoke and carbon monoxide detectors are in operable condition at time of inspection. LPA observed First Aid kit is kept in the converted attached garage activity space. The Licensee has current Pediatric First Aid and CPR. Licensee did not have proof of immunization against influenza (or written declination for this only), pertussis, and measles readily available during today’s inspection. The Licensee and A1 has not taken the Mandated Reporter Training
—CPR Card valid until: 04/23/2024
—Children records and required licensing forms were reviewed and discussed (LIC857 provided) as well as mandated child abuse reporting and criminal record clearance requirement.

The following were discussed:
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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee (or facility representative) 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.

Rooms that are off-limits need to be made inaccessible during operating hours. NO smoking, NO infant walkers, NO Johnny jumpers, NO saucer chairs, NO incline sleepers and any other item that falls into that category are permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.


Report Continues - Page 3 of 4
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018
VISIT DATE: 06/13/2022
NARRATIVE
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The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

LPA discussed the safe sleep regulations with licensee [or 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 licensee [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.

AB 1207: Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: http://www.mandatedreporterca.com/

Senate Bill 792: this bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the visit.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224 form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form during this visit.

Exit interview was conducted and report was reviewed with the Licensee (or facility representative), Silvia Camarena Preciado. Report Ends - Page 4 of 4

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 06/13/2022 03:45 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made of indoor/outdoor space during inspection, LPA daycare activity space to have miscellaneous items (boxes, frames, bags) stacked high and unbalanced against wall. LPA observed mattresses leaned against wall and paint buckets in daycare activity space. LPA toured Living Room, to have dog pee pad with dog pee spots on floor. Side yard area which children will have access to, to have items leaning against the wall such as bed frame, wooden planks, and doors. LPA observed plastic bin filled with children's toys to have dirt, debris, and spider webs. This poses an immediate health, safety, and personal rights risk to children in care.
POC Due Date: 06/20/2022
Plan of Correction
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Licensee states she will provide photos of these items cleared out by POC date via email.
Type A
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 LPA observations and interview at 12:01 PM, LPA observed Bathroom 1, that Licensee states children use, to not have locks on under sink cabinet and drawers which LPA observed contained sharp scissors, multiple shaving tools and blades, Listerine Mouthwash, Clorox, Comet, and other cleaning solutions. This poses an immediate health, safety, and personal rights risk to children in care.
POC Due Date: 06/20/2022
Plan of Correction
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LPA observed Licensee clear out sharp scisorrs, shaving tools and blades during inspection. Licensee states she will clear out the rest of hazardous items and store in back. Licensee states she will provide photo proof by POC date via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 06/13/2022 03:45 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(A)
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. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA obserations and interview, at 12:06 PM, LPA observed Kitchen area, that Licensee states is off limits but has not been made off limits, to contain Black Flag Ant & Roach killer under cabinet sink with inoperable child safety lock. This poses an immediate health, safety, and personal rights risk to children in care.
POC Due Date: 06/13/2022
Plan of Correction
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LPA observed this item to be removed from under cabinet sink and placed in high back laundry space.
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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 06/13/2022 03:45 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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 Based on LPA observation at 12:01 PM, Licensee did not follow safe sleep guidelines by having C1 sleeping in playpen that she can climb in and out of in converted garage daycare space. Licensee did not remove child from playpen once awake and C1 stayed in playpen for an extra 15 minutes. LPA instructed Licensee to remove C1 from playpen during inspection. This is a potential health, safety, and personal rights risk to children in care.
POC Due Date: 06/13/2022
Plan of Correction
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Licensee states that C1 was only sleeping in converted daycare space because she arrived early but Licensee understands there is no sleeping in converted daycare space. Licensee provided written declaration stating she understands regulation requirement and will only allow children to sleep in Living Room.
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
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Based on LPA record review and interview at 1:53 PM, Licensee and A1 did not have proof of completion for mandated reporter training. Licensee states she has not completed it. This poses a potential health, safety, and personal rights risk to children in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee states she and all assistants will complete mandated reporter training and provide proof to LPA by POC date via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 06/13/2022 03:45 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: PRECIADO CAMARENA FAMILY CHILD CARE
FACILITY NUMBER: 198012018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

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 LPA record review and interview at 1:53 PM, Licensee and A1 did not have proof of immunizations for TdaP, MMR, and Influenza (or written declination for this ONLY). Licensee states she did not have it. This poses a potential health, safety, and personal rights risk to children in care.
POC Due Date: 07/13/2022
Plan of Correction
1
2
3
4
Licensee states she will obtain immunization reords and provide proof to LPA by POC date via email.
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 LPA observations and interview, Licensee did not report the conversion of garage into a "child care" room. Licensee states Fire Inspector did come to inspect room but did not have proof of report at time of inspection. This poses a potential health, safety, and personal rights risk to children in care.
POC Due Date: 07/13/2022
Plan of Correction
1
2
3
4
Licensee states she will try to obtain report from Fire Inspector by POC date and provide to LPA via email. Licensee provided written declaration saying children will NOT use converted garage for sleeping.

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8