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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419502
Report Date: 07/27/2026
Date Signed: 07/27/2026 07:01:32 PM

Document Has Been Signed on 07/27/2026 07:01 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BARRERA FAMILY CHILD CAREFACILITY NUMBER:
197419502
ADMINISTRATOR/
DIRECTOR:		BARRERA,THELMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 935-4653
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
07/27/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Thelma Barrera, LicenseeTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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On Monday, July 27, 2026, Licensing Program Analyst (LPA) Sara Rajapakse conducted an unannounced annual inspection and met with licensee, Thelma Barrera, who granted access and guided LPA on a tour of the facility. LPA verified that all adults currently residing or working in the home received a background clearance. Licensee changed the operating hours from a 23-hour daycare to 12 hour daycare, and she provided the LPA an updated LIC 279. Operating hours are Monday to Friday from 6:00 am to 6:00 pm and care is provided for children ages 0 to 12 years old. LPA observed four (4) children (1 infant and 3 school-age children) in care. LPA observed facility to be within ratio. Annual fee is current. Incidental Medical Services (IMS) were discussed, and the licensee confirmed that no children currently require IMS. Licensee provides transportation. LPA observed driver’s license, insurance and registration to be current. There are no bodies of water on the premises.

This facility is a one-story home with three (3) bedrooms and two (2) bathrooms, kitchen, living room, laundry room, attachedattacgarages, front and backyard.

Areas off-limits to children include- two bedrooms, bathroom #2, kitchen, living room, laundry room, attached garage, partial backyard separated by gate door, and front yard. Master bedroom’s door that gives access to the rest of the home has been made into a wall. This property has an ADU that shares a wall with the daycare.
Lady King
Sara Rajapakse Montolla
DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2026
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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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.

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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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Areas accessible to children include- Living room, bedroom #1, bathroom #1 and most of the backyard.

LPA inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, facility has central AC/heater. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. Electrical outlets were covered. LPA observed napping cots and playpen to be in good condition. LPA observed Licensee place child #1, who was drinking milk from a bottle, in a playpen that had blankets, stuffed animals and hanging items. LPA reminded Licensee that playpen and cribs need to be free from loose and/or hanging items. Licensee removed all items including hanging rattle and stationary mobile. Another adult in the home assisted in caring for the infant in the home while visiting. Adult visiting is fingerprinted cleared by the Department, but needs Mandated Reporter Training certificate, proof of immunizations (i.e. Pertussis, Measles, and yearly Influenza), TB clearance test results, and signed LIC 9108.

Bathroom #1: LPA observed the toilet and sink to be clean and operable. There is liquid hand soap by the sink. The cabinet underneath the sink is closed and secured by a child safety lock making stored items inaccessible to children. LPA observed bar soap in the shower. Licensee moved the bar soap to the laundry room make it inaccessible. LPA reminded licensee any personal items (ex; shampoo, mouthwash, bar soap, medication, perfumes, razor blades, air fresheners, nail polish/remover or items that state keep out of reach of children) must be made inaccessible to children.

Backyard: LPA inspected the backyard play area for safety, comfort, and cleanliness. LPA observed the backyard to be fenced, and the side gate closed and locked with a self-latch. A portion of the backyard was inaccessible to children with a gate door. The surface of the outdoor activity space is a combination of concrete and turf and it is maintained in a safe condition. LPA observed play equipment to be age appropriate and in good condition. LPA observed two sheds that were closed and each was secured with a combination master lock. The backyard is free of hazards. The AC/Heating Unit is located on the left side of the home and is inaccessible to children due to a gate door.

Meals: Licensee provides breakfast, lunch and snacks. Licensee participates in the Ventura food program. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name, date and properly stored or refrigerated. Licensee stated there are no children with severe food allergies. Per licensee, the knives and sharp objects are stored inside the upper kitchen cabinet—there is a

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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child safety gate making them inaccessible to children. LPA observed cleaning compounds items stored in the laundry room located in the kitchen with child safety doorknob cover making them inaccessible to children.

Pets/Poison/Firearms/Body of water: LPA asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has one dog (Lasha Apso). LPA observed the dog in the backyard and the dog went to the front yard. Licensee stated that the dog interacts with children outdoors. Per Licensee, there are no poison (e.g. drano, rat poison, etc.), firearms, weapons or bodies of water at the facility. LPA did not observe poisons, firearms, weapons or bodies of water. The licensee was informed that if any firearms are purchased, it is required the firearm and ammunition/firing pins are stored separately and locked with a key or combination lock.



Illness and medication: In case of illness, licensee stated that children will be isolated in the main entrance area until parents pick-up the child. Household medications are stored in laundry room and inaccessible to children—door has a child safety doorknob cover.

Disaster emergency safety: LPAs observed the required 3A40BC fire extinguisher located mounted on the wall by the hallway. LPA observed the valve on the green area indicating fully charged. LPAs observe a service tag dated 8/13/2025. LPA reminded licensee the fire extinguisher must be service annually or show purchase receipt within a year. LPA observed the smoke alarm and carbon monoxide detectors located in the living room. Licensee tested the smoke alarm and carbon monoxide and heard the sound, and they are operable. LPA observed the last disaster emergency drill conducted on 07/16/2026.

LPA observed licensee HSI Child/Infant First Aid/ CPR certification dated 08/30/2024. Licensee has proof of Health and Safety certification, immunization against Pertussis, Measles, and Influenza. Licensee has completed the Child Abuse Mandated Reporter training dated 09/06/2024.

LPA observed the postings License, and Pub 394 Notification of Parents Rights. LPA asked the Licensee to provide facility roster and files for child #1 and child #2. Licensee searched her files and was not able to provide documentation of children records for child #1 and #2. Licensee was able to provide sleeping logs for one day, but not for the rest of the month. LPAs discussed with Licensee, the importance of having children’s records present for LPA to observe and review. Licensee states she understands and will provide proof of documentation to LPAs by 08/11/26. One Type B deficiency was issued.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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The following was also discussed with the licensee:

The following items are zero tolerance:
1. Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09.

2. The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

3. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

4. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

5. In the absence of the licensee, a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), Child Abuse Mandated Reporter Certificate. Licensee’s temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

6. A current roster of enrolled children must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

7. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated.

8. The fire extinguisher type 2A-10BC or 3A40BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

9. Changes should be reported to the Department as soon as they occur such as, but not limited to closures, additional adults residing, construction, remodeling, telephone number changes and/or if you move from your home.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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10. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

11. Fire and disaster drills must be performed at least once every six (6) months and documented for review by the Department.

12. Smoking is prohibited in the family childcare home.



13. Children and staff records must be maintained and updated as needed and be available for review by the Department.

14. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children, including those who reside in the home must have proof of immunization.

15. Inspection Authority: All adults living and working in the home shall be made aware of the Department’s right to inspect the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



16. The facility license number must be on all advertisements, publications, or announcements with the intent of attracting clients.

17. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

18. Liability Insurance was discussed; LPA informed licensee to review Title 22 Regulation 102417(m)(1) for additional information.

19. Dog(s) and/or pets are recommended to be isolated from children in care.

20. Infant walkers, Johnny jumpers, or any other item that falls into this category are not permitted in the facility.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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Licensee Thelma Barrera 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 the safe sleep regulations with licensee Thelma Barrera 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 Thelma Barrera of the importance of checking for and removing any 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 Thelma Barrera was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Thelma Barrera, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502
VISIT DATE: 07/27/2026
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Two Type B deficiencies were issued today in accordance with Title 22 of California Code of Regulations and/or California Health and Safety Code. Please see attached LIC 809-D for citation. Five Technical Violations given. See attached LIC 9101TV
A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. A copy of the Appeal of Rights was given. LIC 126 Checklist for Family Child Care was provided and reviewed. Exit interview conducted and report was reviewed with licensee Thelma Barrera
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sara Rajapakse Montolla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2026 07:01 PM - It Cannot Be Edited


Created By: Sara Rajapakse Montolla On 07/27/2026 at 06:02 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BARRERA FAMILY CHILD CARE
FACILITY NUMBER: 197419502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
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Licensee removed blankets, stuffed animals, hanging items and sheet that was not fitted from playpen immediately. Licensee will contact the Technical Support Program and notify LPA Rajapakse by 8/10/2026. Licensee provided a declaration that she will not place loose and/or handing items in the playpen again.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 children, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2026
Plan of Correction
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Licensee will provide signed LIC 282, LIC 700, LIC 627, LIC 995 and LIC 9150 for both child #1 and child #2. Licensee will also submit immunizations, LIC 9227 Invididual Infant Sleeping Plan and sleeping logs from 7/28 to 8/10. All documents are due to LPA Rajapakse by 8/11/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Sara Rajapakse Montolla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2026


LIC809 (FAS) - (06/04)
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