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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750058
Report Date: 04/23/2025
Date Signed: 04/23/2025 04:38:02 PM

Document Has Been Signed on 04/23/2025 04:38 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KIDS AND KRAYON INFANTS AND TODDLERSFACILITY NUMBER:
197750058
ADMINISTRATOR/
DIRECTOR:		MARIA ELENA VALDOVINOSFACILITY TYPE:
830
ADDRESS:43137 VENTURE ST SUITE 103TELEPHONE:
(661) 839-5252
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 6DATE:
04/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Lead Teacher-Perla ValladaresTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On April 23, 2025, at 12:50 P.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo met with the facility director, Maria Elena Valdovinos, to conduct an unannounced annual/random inspection for the Infant and Toddlers license in accordance with the facility sketch. A tour of the facility was conducted. LPA observed a total of 6 infants and toddlers’ children for the classroom (Yellow Room) with two staff providing care and supervision. The hours of operation are 6:30 A.M. to 6:30 P.M., Monday - Friday. Incidental Medical Services (IMS) was discussed.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; floors of all rooms have a surface that is safe and clean, cleaning compounds are inaccessible, poisons are locked, furniture/equipment is in good condition. Indoor activity space for infants is physically separate from space used by children in the preschool and toddler components. Infant center is equipped with age-appropriate furniture and equipment including cribs, cots, diaper changing table and feeding chairs. Per Director, toys are sanitized and dried out in the sun. Toy are also being used alternately; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual or portable storage space (cubby, individually labelled with name) for his/her clothing and personal belongings. There is a working telephone. Electrical outlets are inaccessible and has plastic covers. Recalled and or prohibited toys or sleep/play equipment were not observed on the premises. There are no window cords accessible to children.

Trash bins have tight fitting lids. Drinking water is available in the infant/toddlers room. Children bring their own bottle/container when drinking. LPA observed a sufficient quantity of cots available for napping toddler and preschool children. LPA also observed cribs, highchairs, and diaper changing table. The bedding is
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2025 04:38 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 04/23/2025 at 03:58 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: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide staff #2 health screening and TB clearance, which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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The director will send the copies of staff #2 health screening and TB clearance to LPA.
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide the following: 1) child #4 and #5 have missing Admission Agreement, 2) child #2 to #5 have missing LIC 627, 3) child #2 to #4 have missing Physicians Reports, 4) child #3 to #5 have missing LIC 613A, 5) child #4 and #5 have missing LIC 995A, and 6) child #2 has missing LIC 9227, which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will send copies of the following documents to LPA: 1) child #4 and #5 Admission Agreement, 2) child #2 to #5 LIC 627, 3) child #2 to #4 Physicians Reports, 4) child #3 to #5 LIC 613A, 5) child #4 and #5 LIC 995A, and 6) child #2 LIC 9227.
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:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


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Document Has Been Signed on 04/23/2025 04:38 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 04/23/2025 at 03:58 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: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide the Needs and Services Plan for child #1 and #5 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will send copies of the Needs and Services Plan for child #1 and #5 to LPA.
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide the immunization records for child #5 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will send copies of the immunization records for child #5 to LPA.
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:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2025 04:38 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 04/23/2025 at 03:58 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: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101427(b)
Infant Care Food Services
(b) There shall be an individual feeding plan for each infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above by failing to provide the Infant Feeding Plan for child #1 and #5 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will send copies of the Infant Feeding Plan for child #1 and #5 to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Joselito DelMundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058
VISIT DATE: 04/23/2025
NARRATIVE
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stored separately. Per Director, when infants have a bowel movement, the soiled diaper is placed in a plastic bag and discarded in the outdoor trash can. All materials and surfaces are toxic free and are inaccessible. There is no fireplace in the facility. The center has an internal pull-down fire alarm system and fire extinguishers. Carbon monoxide devices are in operable condition (tested at 2:45 P.M.).

Restrooms: LPA inspected and observed a total 1 toilet and 1 sink in the bathroom. The LPA observed liquid soap, toilet paper, trash bins with covers, diaper changing table, and disposable gloves were readily available. Water temperature is appropriate. There is an isolation area in the corner of the room beside the cribs for children who become ill while in care and parents are immediately called to pick up their children. The facility maintains a comfortable temperature at all times, first aid supplies, sign in/out sheets are available and completed daily. Smoking is prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed or stored on premises. There is no body of water on the premises.



Napping: LPA observed children's personal blankets. Per Director, they provide sheets for children in care during nap time. Mats are used and maintained in good condition, wiped/cleaned/sanitized, or when soiled and there is no contact with other children bedding.

Outdoor: The facility has a playground area for the infant/toddlers and preschool children. Currently, the outdoor playground is not being used by the infant and toddlers. Per Director Valdovinos, the infants and toddlers just started walking. However, water jug is available when infant/toddlers are doing outdoor play. Outdoor play equipment was inspected for health, safety, good repair, and age appropriateness. LPA observed two canopies at the outdoor playground. The area was observed to be free of debris, free from hazard, holes, broken items, debris. The slides have wood chips to absorb the fall. No bodies of water were observed. According to the director, drinking water is provided during outdoor plays. LPA observed a water jug at the outdoor play area.

Teacher child ratios were observed, and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.



Health Related Services: According to Director Valdovinos, they were not providing medications to children in
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058
VISIT DATE: 04/23/2025
NARRATIVE
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care. LPA observed the facility has missing Infants Needs and Service Plans for child #1 to #5.

Children’s Records: The following were observed during children’s records review: 1) child #4 and #5 have missing Admission Agreement, 2) child #2 to #5 have missing LIC 627, 3) child #2 to #4 have missing Physicians Reports, 4) child #3 to #5 have missing LIC 613A, 5) child #4 and #5 have missing LIC 995A, 6) child #2 has missing LIC 9227, and 7) child has missing immunization records. Type B deficiencies were cited during this inspection.
Director Valdovinos was advised to provide copies of the child’s documents.

Children are inspected for illnesses (wellness policy) as they arrive. Children were check with regards to their body temperature.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Food Service: There is a clean microwave, refrigerators, and freezers available in the facility. Per Director Cuevas, parents bring their own infant formula for their children. LPA observed the infant formulas are individually labeled with child’s name.

Staff/Personnel Records: Director (qualified) qualifications were verified, Designation of Responsibility observed, immunization's, TB clearance for staff, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were observed in file for staff #1. However, staff #2 has missing Pediatric First Aid and CPR, health screening, and TB clearance. Also staff #1 took the online training for the pediatric first aid and CPR. Staff #1 and #2 were advised to take the in-person CPR/First Aid training either through the American Red Cross, American Heart Association, or any Emergency Medical Services Authority (EMSA) approved/accredited training centers.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058
VISIT DATE: 04/23/2025
NARRATIVE
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Facility Records: Roster, fire/disaster drills log was last completed on 03/11/2025. Per Director Valdovinos, they were conducting fire/disaster drills every end of each month. For infants and toddlers, infants were placed inside the movable cribs when conducting fire/disaster drills.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty. The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393), PUB 269 Child Passenger Restraint System Poster, emergency disaster plan, and earthquake preparedness checklist.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.

Advisory/Other: First Aid kit was observed.

Sign in and out sheets were reviewed. The facility is using manual sign in and out sheet and were recorded daily. The parent board was reviewed and has all the required forms posted. Fire/earthquake drills current.

Director was advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of a day care center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.



Director was reminded that all adults 18 and over, 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.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the day care center,
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS AND KRAYON INFANTS AND TODDLERS
FACILITY NUMBER: 197750058
VISIT DATE: 04/23/2025
NARRATIVE
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and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

Type B deficiencies were cited during this inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8:00 A.M. to 5:00 P.M.



Exit interview conducted and a copy of this report, Notice of Site Visit, and appeal rights were provide to Director Maria Elena Valdovinos.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Joselito DelMundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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