<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155620578
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:45:31 PM

Document Has Been Signed on 09/30/2025 04:45 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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:HANEY, SAVANNAH FAMILY CHILD CAREFACILITY NUMBER:
155620578
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
09/30/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Savannah HaneyTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/30/2025 Licensing Program Analyst (LPA), Christopher Burnias conducted an unannounced Annual Random Inspection and was met by licensee Savannah Haney. Days and hours of operation are Monday through Friday from 7:00 AM to 5:30 PM.

LPA toured the home inside and outside and a census was taken. LPA reviewed current facility sketch and confirmed that the dining room, kitchen, living room, restroom, and day care room (converted garage) are used for providing care and are accessible to children. All other rooms are upstairs and off-limits.

This is a two story home and during the inspection, LPA observed that there was no gate or other barrier present to prevent children from accessing the stairs. Licensee placed chairs in front of the stairs to serve as a temporary barrier during the inspection. Citation has been issued. Licensee is to install a gate at bottom of stairwell to prevent children from accessing stairs.

During inspection, LPA observed all accessible areas of the day care to be disorganized with potentially hazardous items cluttered throughout the home that are not safe for children. LPA observed items such as makeup, screws, scented wax melts, small jewelry and other small choking hazards inside accessible areas of the day care. Food messes and trash were also observed in accessible rooms of the day care. Citation has been issued. Licensee is to have all accessible areas of the day care cleaned and organized.

During inspection of the converted garage (day care room), LPA observed accessible drawers containing shampoo, small jewelry, body spray, scissors, push pins, screws, a box of various hardware, deflated balloons, disinfecting spray, full trash cans, and a free standing mirror leaning against a cabinet. Floors were observed to have food messes.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
Document Has Been Signed on 09/30/2025 04:45 PM - It Cannot Be Edited


Created By: Christopher Burnias On 09/30/2025 at 03:44 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(C)
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. (C) Ammunition shall be stored and locked separately from firearms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above. LPA observed accessible ammunition stored in an unlocked drawer in an upstairs bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
1
2
3
4
Licensee is to have ammunition locked and stored in an inaccessible area of the home. Ammunition must be locked and stored separately from firearms. Licensee is to submit proof of securing ammunition in an inaccessible area of the home to the Department. Licensee is to also review regulations related to firearms and ammunition and provide a written statement indicating they have read and understood the regulation and will ensure compliance.
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.
Luisa Gavoutian
NAME OF LICENSING PROGRAM MANAGER:
Christopher Burnias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/30/2025 04:45 PM - It Cannot Be Edited


Created By: Christopher Burnias On 09/30/2025 at 03:44 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above. LPA observed all accessible areas of the day care to not be clean and orderly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
1
2
3
4
Licensee is to have all accessible areas of the day care clean and organized.
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above. LPA observed hazardous items in all accessible areas of the day care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
1
2
3
4
Licensee is to remove any items not intended for use by a child. Licensee is to also remove sharp or pointed items, items that could be a choking hazard, and any other toxic or hazardous items from all accessible areas of the day care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Luisa Gavoutian
NAME OF LICENSING PROGRAM MANAGER:
Christopher Burnias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 09/30/2025 04:45 PM - It Cannot Be Edited


Created By: Christopher Burnias On 09/30/2025 at 03:44 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above. LPA observed that there was no gate installed at the bottom of the stairwell to prevent children from accessing stairs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
1
2
3
4
Licensee is to have a gate installed at bottom of stairwell and submit proof of installation of gate to the Department.
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.
Luisa Gavoutian
NAME OF LICENSING PROGRAM MANAGER:
Christopher Burnias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578
VISIT DATE: 09/30/2025
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
During inspection of the living room, LPA observed small jewelry, nail polish, screws, wrench, small rubber band hair ties, lotion, hair spray, makeup, and deodorant inside drawers and storage boxes on living room couch. LPA also observed a free standing mirror leaning against a wall unanchored. Floors were observed to have food messes.

During inspection of the kitchen area, LPA observed a can of paint accessible on the floor.

During inspection of the dining room, LPA observed exposed hardware and pointed stakes for an unassembled outdoor post kit for outdoor accent lighting. LPA also observed accessible drawers with batteries, screws, and scented wax melts. A set of golf clubs were also observed in the dining room.

During inspection of the backyard, LPA observed a propane tank connected to a fire table.

Citation has been issued for hazardous items being present and accessible. Licensee is to remove any items not intended for use by a child. LPA reminded Licensee to also remove sharp or pointed items, items that could be a choking hazard, and any other toxic or hazardous items from all accessible areas of the day care. Licensee was reminded that it is their responsibility to keep areas clean and organized and provide a safe and healthy environment for children in care.

During inspection, LPA observed doors to the backyard open from the living room along with the door to the backyard open from the converted garage. Licensee did not have an assistant present and children were observed to be scattered in different rooms apart from the Licensee. Licensee was reminded that they must provide active supervision of the children and that keeping children in one room at a time is best to ensure direct supervision. Licensee was also reminded that children shall not be left in parked vehicles.

During inspection, LPA observed ammunition to be stored in an unlocked drawer in an upstairs bedroom. Licensee was reminded that all firearms and ammunition must be locked separately and stored in an inaccessible area of the home. Citation has been issued. An immediate $500.00 civil penalty has been assessed for the unlocked ammunition. During the inspection, Licensee placed the ammunition into a locked closet. Firearm was observed to be locked and made inaccessible.

There is no swimming pool or other bodies of water on the premises.

No poisons were observed during the inspection. Detergents, cleaning compounds and medication are made inaccessible.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578
VISIT DATE: 09/30/2025
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
There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort.

The home has working telephone service and LPA confirmed the phone number on record is correct.

The outdoor play area in the backyard is fenced and safe toys and play equipment are observed.

Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 04/20/2024. Licensee’s pediatric CPR/First Aid certification expires on 04/19/26. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578
VISIT DATE: 09/30/2025
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
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview was conducted and report was reviewed with licensee Savannah Haney. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA verified the RSO profile in FAS.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencies are being cited: (see next page).

Licensee was provided appeal rights.

LPA Burnias informed licensee Savannah Haney that this report dated 09/30/2025 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 Burnias informed the licensee to provide a copy of this licensing report dated 09/30/2025 that documents any Type A citation(s) 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.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HANEY, SAVANNAH FAMILY CHILD CARE
FACILITY NUMBER: 155620578
VISIT DATE: 09/30/2025
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
A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 Acknowledgement of Receipt of Licensing Reports was given to Licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Luisa Gavoutian
NAME OF LICENSING PROGRAM ANALYST: Christopher Burnias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
Page: 10 of 10