304314303-12-26-2023-06-CC-ABOI-CYVQXZ-20231226113422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314303
Report Date: 12/26/2023
Date Signed: 12/26/2023 11:34:38 AM

Document Has Been Signed on 12/26/2023 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	SHIN, STELLA		FACILITY NUMBER:	304314303
ADMINISTRATOR:	SHIN, STELLA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 727-0178
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	12/26/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	SHIN, STELLA		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/26/2023, Licensing Program Analyst (LPA) Bootorabi and Jung conducted an announced, in-person Pre-Licensing inspection for a new large Famiyl Child Care home. The LPA met with applicant SHIN, STELLA, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates that 1 adult lives in the home. The adult resident received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are 0 minors living in the home. The applicant stated that she is not registered with any Resource Foster Care agency and that she does not hold a Resource Foster Parent License. The applicant was reminded to notify the licensing office of any changes.The applicant agrees and states she understands that she is responsible for providing Orange County Community Care Licensing with any changes/updates pertaining to Resource Foster Care. The applicant is requesting a large Family Childcare Home license. Per the applicant, operation hours will be Monday – Friday, 8:00 am – 6:00 p m. The licensee stated she will be providing care and supervision to children ages 2 to 5 year old. The applicant was provided the link for “How Many Children Can Attend a Family Child Care Home?” for further information. https://ccld.childcarevideos.org/family-child-care-providers/how-many-children-can-attend-a-family-child-care-home/ Facility Sketch LIC999: All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a single-story home with 2 bedrooms, 3 bathrooms, a living room, a kitchen, 1 dining room(family room on sketch), a laundry room, a front yard (not fenced), a backyard (fenced), and a garage. There is a fireplace, located in the living room, barricaded by a glass gate and a piano. Page 1

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated identify the entire area. The applicant has a child-proof safety gate in front of the office area, and another gate leading to the off limit areas bedroom #2, and bathroom #2 off limits. Doors will remain closed for the kitchen, and laundry room leading to the garage that is stated to be off limits. The applicant has a lock on the door of the garage ensuring this area is inaccessible to the children in care.
The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary. The backyard has one gate on the side of the house where the AC unit is located and trash bins. The other side is open for children to play in. The off limits areas are as followed: kitchen, bedroom #2, bathroom #2, garage and side of the house where ac unit is located. The front yard will not be accessible for children to play in but will be used for families to come in.

Areas Designated for Day Care Activities: The applicant has designated the living room, half bathroom #3 next the living room, bedroom #1 and bathroom #1 next to bedroom #1, and backyard. The applicant will be using the family room(dining room) to meet with families as need but not be used for children.

The garage will not be used for day-care.

The applicant stated and understood that the garage would be off-limit.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathrooms were observed to be safe and free of hazardous items. The applicant has a small step stools in the children’s bathroom #1. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock.

The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C). PAGE 2

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Smoke and carbon monoxide detectors were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged, as indicated on the service tag observed by the entrance.

OUTDOOR PLAY AREA: The applicant stated the outdoor play activities will be conducted in the backyard. The backyard is appropriately fenced. LPA observed age-appropriate play equipment to be free from hazards. There are no bodies of water on the premises.

FOOD SERVICES
The applicant stated she would provide food for the children and was reminded that if food is brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

NAPPING ARRANGEMENTS
Per the applicant, children will nap in the living room and bedroom #1. The applicant stated children will nap on cots. Parents will bring blankets from home. If children have an accident then blankets will be placed in a plastic bag and parents will take home to clean.
The applicant stated she will not be caring for infants but the following information was discussed:
The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. A Safe Sleep Consultation was provided.
Safe Sleep

LPA discussed the safe sleep regulations with the applicant 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. LPAs also informed the applicant 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.

A sample safe sleep log was provided during today’s visit. LPA also provided an Individual Infant Sleeping Plan LIC 9227 (Español | 한국어 | 中文 | Tiếng Việt) p3

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CPR & FIRST AIDE:
A records review indicates the applicant completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 11/24/2025. A first aid kit is available at the facility in the office area. The LPA provided a consultation regarding staying current on your CPR & FIRST Aide Certifications every 2 years as they expire. https://emsa.ca.gov/childcare_provider/

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, Mandated Reporter, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information promptly. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1.Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2.Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Inspection Authority: All adults living and working in the home shall be made aware of the Department’s right to inspection authority, 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.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

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 applicant has submitted proof of immunization's.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.

The LPA advised the applicant(s) on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 5 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.

STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record
Exemption Transfer Request (LCI 9188).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). ). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

LPA reviewed documents with the applicant. The applicant received printed forms and sample forms. The applicant had no further questions at this time.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 6 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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, before 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.

Because the [applicant, or licensee] rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm Incidental Medical Services (IMS) - Family Child Care Homes

Review of records to be maintained:LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant. LPA discussed Title 22, Div 12, Chap 3, Family Child Care Homes with applicant.

A riview of documentation and copies of LIC forms were provided during todays visit. The applicant stated they did not have further questions.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On this date, 12/14/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses under information shared by the California DOJ.

The applicant was informed of the MyChildCarePlan.org site, 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.

An exit interview was conducted and the report was reviewed with the [applicant, licensee, or facility representative]. Please include their name. Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. The applicant signed up during today's inspection.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SHIN, STELLA	FACILITY NUMBER: 304314303
	VISIT DATE: 12/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The applicant signed up for updated during today’s inspection.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The Large Family Child Care Home was not in compliance with Title 22 Regulations at the time of inspection. The applicant is required to submit the following corrections to the licensing office by the due date of 12/29/2023 .

1.Licensing Posting Requirements Posting
2. Updated Facility Sketch

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 9 of 9