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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609020
Report Date: 11/04/2021
Date Signed: 11/04/2021 08:13:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2019 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20191112154840
FACILITY NAME:COMFORT ELDERLY CARE, INC.FACILITY NUMBER:
197609020
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:6701 CANTALOUPE AVETELEPHONE:
(818) 602-1622
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:0CENSUS: 0DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Naira ParoyanTIME COMPLETED:
08:15 PM
ALLEGATION(S):
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Facility staff influenced a resident for personal gain.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan to deliver the finding for the allegation listed above. Upon arrival LPA met with staff. Administrator Naira Paroyan arrived to the facility approximately 6:07 pm.

Regarding the allegation, it is being alleged that Licensee Representative/Administrator, Diana Makhtesyan and Assistant Administrator, Melissa Shirickchyan influenced/pressured Resident 1 (R1) to deed his properties to his significant others adopted son.

The allegation was referred to Community Care Licensing Division’s Audit Department and assigned to Auditor, Jorge Mojica, who would investigate the following: Objective 1- Determine if the Licensee Representative/Administrator and Assistant Administrator applied undue influence on R1. Objective 2: Determine if the Licensee Representative/Administrator and Assistant Administrator were involved in the sale of R1’s properties.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
VISIT DATE: 11/04/2021
NARRATIVE
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An initial 10-day complaint visit was conducted on 11/29/2019 by LPA Elizabeth Arambulo. During the visit, LPA Arambulo conducted an interview with the Licensee Representative/Administrator, Diana Makhtesyan, (who will be identified as the ‘administrator’ throughout the rest of the report) between 11:00 a.m. and 3:30 p.m. and obtained a written statement from the administrator regarding the allegation. LPA Arambulo also conducted a subsequent complaint visit on 2/19/2020 to review staff files between 1:10 p.m. and 2:30 p.m.

On 02/24/2020, the auditor conducted an interview with a family member of R1 who reported the following: The family member’s spouse received a call from R1’s longtime significant other, who lived at a separate address; and, who notified them of R1’s passing on 10/06/2019. On 10/10/2019, the family member flew to California and went to R1’s house to offer condolences. During the visit, the family member stated that R1’s significant other’s purpose for notifying the family member was because they wanted assistance in accessing R1’s safety deposit box. On the same day, the family member’s sibling drove to R1’s home from their home. The two (2) family members intended to clean R1’s house, attempt to locate R1’s Will and the key to the bank safety deposit box. However, R1’s significant other did not allow them in and made an inappropriate comment regarding who was going to receive R1’s inheritance. Later in the day, R1’s family member received a call from the adopted child of R1’s significant other (who will from here on out be referred to as ‘child’), telling them to not go to R1’s home. R1’s family members had to return home due to the passing of R1’s sole remaining sibling. When R1’s family member returned, the family member conducted their own investigation. The investigation revealed that R1 had an account at a financial institution with a substantial amount of money; and, another account for a business owned by R1. R1’s family member contacted the company selling R1’s home. The information R1’s family member received was that the home was being sold by the administrator and the signed deeds were notarized by the assistant administrator. R1’s family member also informed the auditor that because there is no executor to R1’s Will, the family member hired an attorney to become the administrator of R1’s will as the family member is the nearest blood relative.

On 02/25/2020, R1’s family member forwarded a picture of a signed, cancelled check to the auditor, which was used to compare with the signatures on R1’s facility records. The auditor used this photo to determine that R1’s Admission Agreement was not signed by R1 and was signed by R1’s significant other’s child when admitting R1 to the facility.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
VISIT DATE: 11/04/2021
NARRATIVE
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On 12/28/2020, the auditor conducted an interview with the administrator. Per the administrator, R1 had stated that R1 would like to gift R1’s properties to R1’s significant other’s child. Per the administrator, R1 wanted to show R1’s appreciation because the child was living with R1 and caring for R1 prior to R1’s admission to the facility.

On 12/29/2020, the auditor conducted an interview with the assistant administrator. Per the assistant administrator, “one day” the administrator asked if the assistant administrator “could do a favor for” R1 because R1 could not walk and was unable to travel. The administrator asked the assistant administrator to notarize the deeded properties without R1 paying for the services. The assistant administrator could not recall the reason given by the administrator as to why she could not be paid. On 01/05/2021, the assistant administrator provided a copy of her notarial journal to the auditor.

On 01/19/2021, auditor Mojica received R1’s Admission Agreement, Physicians Report (LIC602A) Preplacement Appraisal (LIC603), Resident Appraisal (LIC603A), Appraisal Needs and Services Plan (LIC625), documents from the Hospice Agency, the facility Sign in/Sign out sheet and documents pertaining to the sale of R1’s home. On 03/12/2021, the auditor received the Centrally Stored Medication & Destruction Record for R1. While conducting a review of the documents, the auditor observed that R1’s Physician’s Report, dated 9/24/2019, was signed by a physician and the child of R1’s significant other, who identified themselves as R1’s legal representative. Per the Physician’s Report, R1 is incapable of managing R1’s own cash resources; however, on the Pre-Placement Appraisal, the administrator signed that R1 is capable of managing R1’s own cash resources. The Pre-Placement Appraisal contradicts the information provided by R1’s physician. The audit report notes that a Pre-Placement Appraisal is to be obtained from the resident and/or responsible person; however, it does not serve as a substitute for the Physician’s Report.

On 2/10/2021, auditor Mojica conducted a telephone conference with the administrator, who was accompanied by her attorney. The following information was provided during the telephone conference. The administrator did not meet with R1 and R1’s family at the time of admission, as required in their Admission Agreement, section titled, “Intake Procedure for Placement in an RCFE’, section A. The administrator did not consult with R1’s primary or secondary physician; or, any other care provider to obtain information on R1’s health condition as documented in the Admission Agreement section, titled “Intake Procedure for Placement in an RCFE”, section A, C and B, D. The administrator failed to take appropriate action prior to documenting that R1 is able to manage R1’s own cash resources as evidenced by her signature on LIC 603 and 603A.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
VISIT DATE: 11/04/2021
NARRATIVE
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Auditor Mojica conducted a review of records from R1’s hospice agency and observed that hospice services began on 10/01/2019. The hospice enrollment documents were signed by the R1’s significant other’s child who identified themselves as R1’s primary care giver and legally recognized decisionmaker. The hospice records also identified twelve (12) distinct medications prescribed to R1, which were also documented on the administrator’s Centrally Stored Medication and Destruction Record.

When interviewed by LPA Arambulo on 11/21/2019, the administrator reported that she and R1’s significant other asked the significant other’s child to become R1’s Power of Attorney (POA,) which the child initially agreed to do, but refused later on. During the interview, the administrator acknowledged that she was aware that neither R1’s significant other or the significant other’s child were POA for R1.

The administrator also informed LPA Arambulo that R1’s significant other was attempting to marry R1 on R1’s death bed and asked the administrator on how they can get a minister to marry them before R1 passed.

The administrator did not request and/or observed any POA letter or proof that the significant other’s child was also R1’s adopted child. In one medical document, the individual referred to themselves as R1’s surrogate child. Other information obtained during the course of the investigation revealed that the administrator considered R1 as having dementia and knowingly asked for the significant other’s child to become R1’s POA without confirming the relationship.

The investigation revealed that R1 did not have full mental capacity upon admission to the facility, as demonstrated by the significant other’s adopted child signing all the requisite forms under various guises. In addition, R1’s medical records verified this information. The auditor found that it was evident that R1’s significant other and their adopted child took advantage of R1’s weakened condition to misappropriate R1’s properties, judging by the fact that they were aware of R1 having family (blood relatives), but did not contact them until after R1’s passing.

In regard to the second objective, Auditor Mojica conducted a review of the assistant administrator’s notarial journal documentation pertaining to R1. Review of the journal revealed that the assistant administrator notarized the deeds to R1’s properties to R1’s significant other’s adopted child on 10/02/2019, which was one (1) day after R1 was admitted to hospice care four (4) days before R1’s death.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
VISIT DATE: 11/04/2021
NARRATIVE
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The notarization of the deeds were completed at the request of the administrator (without remuneration), not R1. The assistant administrator is a certified administrator who is familiar with all applicable requirements/laws pertaining to mental capacity, health conditions and a resident’s capability to provide consent. The assistant administrator should not have completed the notarization for R1 because she is the assistant administrator for the facility and was aware of R1’s mental and physical condition. Auditor Mojica conducted review of documents received on 01/19/2021 pertaining to the sale of R1’s home. Upon review of the document’s, the auditor noted the following: 1) The administrator was the listing agent for the property owned by R1. 2) The administrator received 3.5 % commission totaling $17,675 (3.5 % x $505,000). 3) R1’s home was listed on Multiple Listing Services at $520,000 and sold for $505,000, due to the extensive repairs needed. 4) The property was listed on 10/17/2019 and sold on 11/03/2019, twenty-eight (28) days after R1’s death, which occurred on 10/06/2019.

Other information obtained during the course of the investigation revealed the following: The administrator made contradictory statements when interviewed by the auditor on 2/10/2021; compared to the statements made to LPA Arambulo on 11/21/2019. On 2/10/2021, the administrator stated that after R1 had passed, the significant other’s child went to pick up R1’s belongings. On that day, R1’s significant other’s child informed the administrator that they were having trouble refinancing the property. The administrator told the them that she could help them sell it, because they couldn’t refinance the home. R1’s significant other’s child was “looking for help”. However, on 11/21/2019, the administrator informed LPA Arambulo that before R1 died, R1’s significant other’s child was trying to get a loan off of the property to pay off the property tax and to pay off the loan that R1’s significant other had against the property. R1’s significant other’s child had been attempting to obtain a loan for two (2) years but was unable to do so. Because the child was not able to get the loan, they wanted to sell the property in hopes of getting money from the sale.

Based on the information provided to LPA Arambulo, it is evident that the administrator was fully informed and aware of R1’s significant other and the significant other’s child’s efforts to get a significant amount of money from R1’s home, even prior to R1’s death. Auditor Mojica concluded that the administrator engaged in conduct that is inimical, in her willful or negligent failure to safeguard the resident’s assets by: 1) Not complying with all terms and conditions set forth in the resident’s admission agreement. 2) Not conducting proper Assessment prior to documenting R1 as being capable to manage his own cash resources/assets, 3) Not reporting the questionable activities of R1’s significant other and alleged adopted child to the proper agencies.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
VISIT DATE: 11/04/2021
NARRATIVE
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 3) Noting R1’s dementia diagnosis but not bringing it to the attention of R1’s physician. 3) Asking R1’s significant other’s child to become R1’s POA while noting R1’s dementia diagnosis and knowing that R1 was allegedly heavily medicated at the time. 4) Failing in her fiduciary duty to safeguard R1’s assets by knowingly, willingly, participating and assisting in the misappropriation of R1’s properties. In addition, Auditor Mojica concluded that: 5) The administrator sold R1’s home and requested the assistant administrator to notarize R1’s deeded properties without confirming that R1’s significant other’s child was a legally adopted child of R1. 6) The administrator engaged in financial malfeasance by acting in her own self-interest by selling R1’s misappropriated home in exchange for a $17,675 sales commission.

Based on the information obtained during the course of the Audit investigation, the department has obtained extensive information to determine that Resident 1 (R1) was taken advantage of and financially abused while living at the facility for only seven (7) days. During this time, the administrator engaged in conduct that is inimical to R1 and engaged in acts of financial malfeasance in her willful or negligent failure to safeguard R1’s properties.

The administrator and assistant administrator facilitated for the child of R1’s significant other, who was essentially a stranger with no known relations, to become POA of R1’s estate, by aiding, abetting or permitting the misappropriation of R1’s three (3) properties; one (1) home and two (2) vacant lots; and, selling the home in exchange for a $17,675 sales commission. Therefore, the allegation of Facility staff influenced a resident for personal gain is Substantiated.

This report was issued to newly hired administrator at the licensees new location facility # 195850162. A change of location application was submitted to the Department on 3/11/2021. The change of location application was approved on 5/6/2021.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 9099-D). Exit interview conducted and Copy report emailed to COMFORTELDERLYCARE@YAHOO.COM and DIANANOTARY@YAHOO.COM
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
ILS
15630(b)(1)
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Any mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, 15610.63, abandonment, abduction
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This Requirement was not met as Evidenced by: Based on information obtained during the course of the audit investigation which revealed that the licensee did not comply with the cited section above by not reporting the attempts to misappropriate R1's properties which posed an immediate health and safety and personal rights risk to R1
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isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible.
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The licensee/Administrator Diana Makhtesyan will submit a written explanation for her actions pertaining to Resident 1 (R1)
CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
87468.2(a)(8)
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87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities. … :To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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and engaging in financial malfeasance in, aiding, abetting, or permitting the misappropriation of the R1's properties and sale of R1’s home which posed an immediate health and safety and personal rights risk to R1.
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Based on the information obtained during the Audit investigation, the licensee did not comply with the section cited above by engaging in conduct that is inimical in her willful/negligent failure to safeguard R1's assets ...
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The licensee/Administrator Diana Makhtesyan will submit a written explanation for her actions pertaining to Resident 1 (R1).
Type A
CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 31-AS-20191112154840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COMFORT ELDERLY CARE, INC.
FACILITY NUMBER: 197609020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
87507(c)(f)
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(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any and the licensee of the licensee’s designated representative no later than 7 days following admission. following admission. (f) The licensee shall comply with all applicable terms and conditions set forth
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and safety and personal rights risk to R1. Licensee/Administrator Diana Makhtesyan will review the regulations cited and submit a written statement that she has read, understands the regulation and will ensure to follow them at all times.
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in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced By: Based on information obtained during the audit investigation licensee did not comply with the section cited by not complying with all terms and conditions set forth in R1's admission agreement which posed an immediate health
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9