334842369-9-7-2023-09-CC-EJOS-CVFSLV-20230907135857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334842369
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:59:13 PM

Document Has Been Signed on 09/07/2023 01:59 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	CALVARY CHRISTIAN PRESCHOOL		FACILITY NUMBER:	334842369
ADMINISTRATOR:	MELISSA BRANDT		FACILITY TYPE:	850
ADDRESS:	1325 MOUNTAIN AVENUE		TELEPHONE:	(951) 849-1877
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	44	CENSUS: 36	DATE:	09/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Karla Bonilla, Director		TIME COMPLETED:	02:15 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	Licensing Program Analyst (LPA), Elyse Jones conducted an annual inspection. A tour of the inside and outside of the facility was granted and the following was observed and/or noted: This is not a combination center. A review of staff and children's records were conducted as part of this evaluation. · The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days: 1. LIC 500 Personnel Report 2. LIC 610 Emergency & Disaster Plan 3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made) 4. LIC 309 Administrative Organization (only if changes have been made) 5. LIC 308 Designation of Administrative Responsibility (only if changes have been made) · The following items have been posted and are updated where necessary: - License - Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148) - Parent’s Rights Poster (PUB393) - Personal Rights (LIC613A) - Child Car Seat Law - Menu · The facility is operating with the limits as stated on the license. · Ratios are being met during this inspection

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101238(g)

Buildings and Grounds

(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, the Licensee did not meet the above regulation poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA overserved several items in all classrooms that are labeled “Keep Out of Reach of Children”. Items included medication, non-blunted scissors, paint, cleaning products, hand sanitizer, etc.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Corrected during inspection. Director understands all items labeled “Keep Out of Reach of Children” and all hazardous items must be stored away from children in care.

Type A

Section Cited

CCR

101170(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation poses an immediate Health, Safety & Personal Rights risk to the children in care. During the file review it was discovered S1 was not associated to the facility. Director stated the former Director wrote in the staff name to be associated on the LIC555 and a letter was sent into the Department to associate, however, the proper steps were not taken to associate staff.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Corrected during inspection. Director was informed of the proper steps and understands the steps to associate staff in the future. Civil Penalty of $500 is assessed.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101216.1(c)

Teacher Qualifications and Duties

(c) To be a fully qualified teacher, a teacher shall have one of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation and record review, the Licensee did not meet the above regulation poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA overserved S3 providing Supervision & Care to 12 children and supervising one Aide (S4). Upon reviewing the file of S3 it was determined only six units have been completed.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	An Aide shall work under a fully qualified teacher. Director understands S3 cannot supervisor an Aide. A written statement was provided during inspection.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

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 the record review, the Licensee did not meet the above regulation poses a potential Health, Safety & Personal Rights risk to the children in care. During the file review it was discovered S3 did not have AB1207 Mandated Reporter completed.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Director agrees to have S3 complete AB1207 Mandated Reporter. Director understands all staff shall have General and AB1207 Mandated Reporter training completed every two years. Certificate of completion is due to the Department on or by POC due date of 9/30/2023.

Type B

Section Cited

CCR

101215.1(m)

Child Care Center Director Qualifications and Duties

(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation poses a potential Health, Safety & Personal Rights risk to the children in care. During the file review it was discovered the facility does not have a staff member with Health & Safety training.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Director agreed to take the Health and Safety training as part of the requirements for the Directors Packet. Director understands there shall be at least one staff with the Health & Safety training during days/hours of operation. Certificate of completion is due to the Department on or by POC due date of 9/30/2023.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation poses a potential Health, Safety & Personal Rights risk to the children in care. During the file review it was discovered that all staff have CPR/1st Aid training, however, the training is not through an EMSA approved vender.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Director agrees to have staff complete CPR/1st Aid training through an EMSA approved vendor. Director understands that there shall be at least one staff with EMSA approved training during days/hours of operation. Proof of completion is due to the Department on or by POC due date of 9/30/2023.

Type B

Section Cited

CCR

101216.1(b)(2)

Teacher Qualifications and Duties

(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below: (2) A teacher shall meet the requirements of Health and Safety Code Section 1597.055. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Cited in error
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Cited in error

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101212(b)

Reporting Requirements

(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, interview and record review, the Licensee did not meet the above regulation poses a potential Health, Safety & Personal Rights risk to the children in care. Upon arrival LPA was greeted by Mrs. Bonilla who identified herself as the current facility Director. However, the Department did not receive notification or a Directors packet.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	During the inspection the Director provided partial packet. The remaining documents needed are the Healthy & Safety Training, Record Keeping Orientation. Remaining documents are due to the Department on or by POC due date of 9/30/2023.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
	VISIT DATE: 09/07/2023

NARRATIVE

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·Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards.
· There are no weapons present at the facility as stated by Karla Bonilla, Director.
· There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Present for supply drinking water in the indoor activity space
· Medications are stored where inaccessible to children
· Hazards are were not stored inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are locked
· All floors shall be clean and safe
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Facility does not provide snacks or lunch
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair
· Facility has an emergency menu. However, facility does not provided snack or lunch. Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· Uncontaminated drinking water shall be readily available both indoors and outdoors and provided by
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall
· Sign in/Sign out record was reviewed and meets regulation requirements
· A Staff member is not present with current EMSA approved Pediatric CPR/First Aid
· Director completed Health and Safety Training- Not available for review

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
	VISIT DATE: 09/07/2023

NARRATIVE

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·A review of children’s records was conducted, and records were found to be complete during this inspection.
· Disaster drills to be conducted every six months – last drill conducted on March 18, 2023
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· A review of staff records on 9-7-2023 indicates that all facility staff or other individuals who require caregiver background checks do not have received criminal record and child abuse index clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
· A review of staff records indicates that all staff present meet minimum qualifications for the position for which they were hired.

LPA discussed the safe sleep regulations with Karla Bonilla, Director 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 Karla Bonilla, Director 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes 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

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
	VISIT DATE: 09/07/2023

NARRATIVE

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Karla Bonilla, Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Child Care Center. 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:

1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHRISTIAN PRESCHOOL	FACILITY NUMBER: 334842369
	VISIT DATE: 09/07/2023

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 26 27 28 29 30 31 32	Exit interview conducted and report was reviewed with Karla Bonilla, Director. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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