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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021622
Report Date: 11/12/2025
Date Signed: 11/12/2025 12:24:40 PM

Document Has Been Signed on 11/12/2025 12:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SARGSYAN FAMILY CHILD CAREFACILITY NUMBER:
198021622
ADMINISTRATOR/
DIRECTOR:		SARGSYAN, NAIRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 229-5907
CITY:LOS ANGELESSTATE: CAZIP CODE:
90038
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
11/12/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Naira Sargsyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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ANNUAL/RANDOM INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced Annual/ Random inspection to the above facility on 11/12/25. LPA arrived at the facility at 9:00 AM and met with licensee, Naira Sargsyan who guided analyst on a tour of the facility. Also present during this inspection were Mariam Baghdasaryan and Anahit Sargsyan, licensee's assistants. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee. Per licensee, facility operation hours are Monday to Friday, 8:00 a.m. to 5:00 p.m., Licensee states she cares for children 3 months old to 13 years old.

This is a one story home located on the first level. The home consists of 3 bedrooms, 2 restrooms, living room, dining room, kitchen, and front yard. Per licensee, during pick up and drop off time she leaves the front main gate open to let the parents enter the yard and drop off and pick up the children from the main entrance door which leads to the living room.

There are two other homes on this property with separated addresses. The front home is 5426 Lemon Grove, Los Angeles, CA 90038 and 5424 Lemon Grove, Los Angeles, CA 90038. Licensee's family members reside at these two addresses who have criminal record clearances on licensing information system. Licensee's daughter, Mariam Baghdasaryan who resides at 5424 Lemon Grove Ave., Los Angeles, CA 90038 is family child care home licensee/provider with facility number 198021623.

Per licensee the children use the bathroom in the hallway, living room, dining room, kitchen, three bedrooms, and front yard. Per licensee areas off limits to children and parents include: Bathroom in the master bedroom. LPA did not observe any stairs in the home during this inspection. Per licensee, she uses the master bedroom as napping room since last month, and it was not reported to Regional office prior changes. LPA approved for licensee to use the master bedroom as daycare area during this inspection.
REPORT CONTINUES ON NEXT PAGE 1 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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 8
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622
VISIT DATE: 11/12/2025
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During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report.

Per licensee, she uses the front yard on a staggered schedule in the mornings with her daughter, Mariam Baghdasarya daycare, 198021623. Licensee uses the front yard from 10:00 AM to 10:30 AM and Baghdasaryan Family Child Care uses the front yard from 10:45AM to 11:15 AM. Per licensee, she uses the front yard in the afternoon and Baghdasaryan Family Child Care uses the side yard in the afternoon which is separated by three feet high gate. Per licensee, she never commingle her daycare children with Baghdasaryan Family Child Care. Per licensee, Baghdasaryan Family Child Care, 198021623 licensee has not enrolled children in her daycare since she has been licensed.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 9:10 a.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with the entry way which lead directly to the living room and dining room. The living room and dining room were inspected and electrical outlets were observed to be covered. LPA observed children toys, one high chair, tables and chairs in the living room and dining room. LPA observed 9 children were playing in the living room, three being infants with licensee and her two assistants. Next to the living room, The kitchen was inspected, and LPA observed child safety latches on the cabinets which stores cleaning compounds and sharp items. Next LPA toured the bedroom adjacent to the living room and observed a desk in the bedroom. Next LPA toured the master bedroom and observed a pack n' play, children napping cots and a foldable sofa bed in the master bedroom. Next LPA toured the off-limit bathroom in the master bedroom and did not observe any hazards. Next LPA toured the bathroom in the hallway and did not observe any hazards. Next LPA toured the last bedroom in the hallway and observed two pack n' plays and one crib in the bedroom. There is a door in the last bedroom which leads to off-limit back area. LPA observed an operable door alarm on the door. LPA did not observe accessible hazards. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the kitchen. It was purchased on 05/28/24 as read by LPA from the receipt, and it was not serviced annually as it is required. Licensee tested the carbon monoxide and smoke detectors in the living room. It sounded off the alarms and heard by LPA to be functional. Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.
REPORT CONTINUES ON NEXT PAGE 2 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622
VISIT DATE: 11/12/2025
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Next LPA toured the front yard fenced. Per licensee, children use the front yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed a three feet high gate in the front yard prior to the main gate which is six feet high. LPA observed that the outdoor yard has toys and other materials for children to play with. Per licensee, she closes the main gate around 9:30 AM after drop off time. There is a door in the front yard which leads to the front main home. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided.

Per licensee, she provides food for children in care. Licensee was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated. Per Licensee, Naira Sargsyan at 10:13 a.m there are no pets, weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises.

The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. During this inspection 9 children were present in the facility, 3 being infants with licensee and her two assistants. All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, Naira Sargsyan at 10:30 a.m. currently she has 9 assistants. Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.



The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 12/2026. Licensee, Naira Sargsyan completed required mandated reporter training on 09/24/24. There are first aid supplies available on the premises. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children. Per licensee, she does not provide transportation.

At 10:50 a.m., per licensee she does not have current facility roster for review. Per licensee currently there are 14 children enrolled, three being infants, two being school age. LPA reviewed 7 children's records, including emergency information from 14 enrolled children, and all 7 reviewed files were completed.
REPORT CONTINUES ON NEXT PAGE 3 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622
VISIT DATE: 11/12/2025
NARRATIVE
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The licensee and her assistants have proof of immunization against influenza, pertussis, and measles. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 10/28/25.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall in the living room. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours.

Per licensee she does not carry liability insurance or a bond in accordance with standard established by Family Child Care statue. Signed statements (LIC282) on 7 reviewed files.

Licensee RENTS/LEASES THE HOME: The licensee provided proof of control of property. Licensee rents the home and has landlord consent form on file. Licensee confirmed that LIC 9149 was signed by landlord.

INFANT CARE: Licensee states that currently she has three infants enrolled in her daycare. Licensee states that the infants sleep in the two bedrooms with door open and living room where they are constantly supervised. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. Per licensee, they check on the napping infants every 15 minutes but they did not document it on the napping chart. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee.



LPA discussed the 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-and-resources/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.
REPORT CONTINUES ON NEXT PAGE 4 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622
VISIT DATE: 11/12/2025
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Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.



The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Licensee 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, Naira Sargsyan 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 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Naira Sargsyan.

REPORT END 5 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/12/2025 12:24 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 11/12/2025 at 11:21 AM
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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on tour of the facility, the licensee did not comply with the section cited above and fire extinguisher was not service annually as it is required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Per licensee, she will buy a new fire extinguisher by plan of correction due date, 11/28/25.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee statement, the licensee did not comply with the section cited above per licensee staff check on napping infants every 15 minutes but they did not document it on nap chart which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Per licensee, effective today they will complete infant nap chart every 15 minutes on napping infants.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 11/12/2025 12:24 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 11/12/2025 at 11:21 AM
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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above and licensee uses the off-limit master bedroom as daycare nap room and it was not reported to the department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Per licensee, she will ensure to report any changes to the department prior using it for children. An updated facility sketch will be submitted to LPA by 11/28/25.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee statement the licensee did not comply with the section cited above and licensee did not have current facility roster during this inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2025
Plan of Correction
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Per licensee, she will have current facility roster by 11/29/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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