364819492-8-14-2025-12-CC-MRIA-DKJUTE-20250814155150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364819492
Report Date: 08/14/2025
Date Signed: 08/14/2025 03:52:26 PM

Document Has Been Signed on 08/14/2025 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	KIDS DISCOVERY WORLD		FACILITY NUMBER:	364819492
ADMINISTRATOR/ DIRECTOR:	MALKANTHI FERNANDO		FACILITY TYPE:	850
ADDRESS:	15858 BEAR VALLEY ROAD		TELEPHONE:	(760) 241-2416
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY: 72	TOTAL ENROLLED CHILDREN: 72	CENSUS: 26	DATE:	08/14/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Malkkanthi Fernando, Director		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 Thursday, August 14, 2025, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with director Malkanthi Fernando who granted access and guided LPA Rivera on a tour of the facility. This is a preschool program that serves children ages 2 to 5 years. This program operates Monday to Friday 6:15 a.m. – 6:30 p.m. Sign in and out takes place at the main entrance area. All areas identified on the facility sketch were toured and inspected both indoors and outdoors. Teacher and child ratio were observed. Present staff are background cleared and 3 present staff have current pediatric first aid/CPR certification. Outdoor playground waiver on file to share with infant 364819494 program. Annual fee is current. LPA entered classroom 2’s. LPA Rivera observed 9 children napping and staff #1 and staff #2 present supervising the children. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed a cubby for children to store their personal belongings. LPA observed cleaning solutions stored inside top cabinet with a child proof lock making it inaccessible for children to reach and open. LPA Rivera observed a step trash bin with a lid. LPA entered classroom 3’s. LPA Rivera observed 17 children napping and staff #3 and staff #4 present supervising the children. Classrooms 3’s and 4’s were combined during naptime. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 08/14/2025 03:52 PM - It Cannot Be Edited

Created By: Mayra Rivera On 08/14/2025 at 02:32 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 DISCOVERY WORLD	FACILITY NUMBER: 364819492
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2025

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
1 2 3 4	Based on record review, the facility did not comply with the section cited above in staff #1, staff #2, staff #3 and Staff #4 missing LIC 503 Health Screening Report including TB test which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2025
	Plan of Correction
1 2 3 4	Director Malkanthi Fernando stated, will inform staff to go get their health screening and will provide LPA Rivera copies of LIC 503 and TB by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Mayra Rivera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

NARRATIVE

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and age-appropriate toys accessible to children. LPA observed a cubby for children to store their personal belongings. LPA observed cleaning solutions stored inside top cabinet making it inaccessible for children to reach and open. LPA Rivera observed a step trash bin with a lid.

LPA entered classroom 4’s. LPA Rivera did not observed children. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed a cubby for children to store their personal belongings. LPA observed cleaning solutions stored inside the top cabinet making it inaccessible for children to reach. LPA Rivera observed a step trash bin with a lid.
LPA entered classroom 5’s. LPA Rivera did not observed children. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed a cubby for children to store their personal belongings. LPA observed cleaning solutions stored inside the top cabinet making it inaccessible for children to reach. LPA Rivera observed a step trash bin with a lid.

Heating, lighting, and ventilation were evaluated by LPA Rivera. LPA observed central AC/heater and vents located on the ceiling. LPA observed the thermostats located in classrooms 2’s and 3’s and temperatures to be between 70-73 degrees. Smoke detectors were not tested during this visit due to the detectors being wired to the emergency pull down fire alarm system. LPA tested the carbon monoxide detector in classroom 3’s and heard the sound. It is operable. The last emergency drill was conducted on 2/11/25. LPA reminded director emergency drills must be conducted every six months. LPA observed napping equipment mats to be in good condition and stored in the classrooms. First aid kit supplies are kept inside the classrooms and LPA observed the kits to be fully equipped. During this visit, per director Malkanthi, stated currently has no children with medication or severe food allergies. LPA Rivera asked if there were any poisons, firearms, weapons, or bodies of water. Director Malkanthi stated no firearms, weapons, no poisons nor bodies of water. LPA did not observe firearms or weapons, poisons, nor bodies of water. Director Malkanthi stated the ill isolation area takes place in the director’s office and children utilize the restroom located in the 2’s classroom.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

NARRATIVE

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LPA Rivera observed the restrooms to be located in the classrooms. LPA observed the restrooms to be in good condition with working toilets, sinks, hand soap dispenser and paper towels. LPA observed a total of 5 toilets and 4 hand washing sinks.

LPA Rivera entered the outdoor play area. LPA Rivera observed the equipment to be in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate and areas around or under high climbing equipment, are cushioned with woodchips and grass turf that may absorb a fall. For adequate shade, LPA Rivera observed a pergola and two gazebos. LPA observed the playground yard to be fenced, and the side gates closed and locked with a keypad lock. LPA observed 2 trash bins with tight lids. For outdoor water drinking, staff bring out water jugs and disposable cups.

This program provides snacks and meals. Meals and snacks are prepared onsite. LPA Rivera informed director Malkanthi Fernando any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. For water drinking, LPA Rivera observed water pitchers and children personal sippy cups in the classrooms. LPA observed the food preparation area to be clean and free of litter, rubbish, rodents, and/or any other vermin and storage containers for solid waste, including moveable bins with tight-fitting covers that are kept on, and in good repair. The facility was observed to be free of flies, other insects, and rodents. Lead testing was conducted on 10/21/2022 and no lead exceedance.

The following documents were posted in a prominent, publicly accessible area at the facility: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and Earthquake Preparedness (LIC 9148). PUB 269 Child Passenger System Poster, and Daily Schedule. LPA Rivera observed sign in/out sheets and observed 26 signed in signatures.

LPA Rivera reviewed the children’s roster, children’s files and staff files and observed children files to be complete. LPA observed staff files to be incomplete. Staff #1, Staff # 2, Staff #3 and Staff # 4 missing LIC 503 Health Screening Report and TB test. Staff #4 missing proof of MMR, TDAP, INFLUENZA. LPA reminded director of as September 2016, it’s a requirement for staff to be immunized against MMR, TDAP, INFLUENZA or declination for influenza.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

NARRATIVE

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LPA Rivera did not observe director Pediatric First Aid/CPR. LPA observed director Malkanthi Fernando Preventative Health and Safety certification credited by North Orange Community College District dated 6/28/2003 and has proof of immunization against Pertussis, MMR and Influenza declination. Director has completed the child abuse mandated reporter training dated 6/24/25. Director was reminded that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

Items discussed during this visit with director:

1. The following items are prohibited by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

4.LIC 125 Entrance Checklist for Child Care Center: LPAs advised that forms, regulations, and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.

5.Pediatric First Aid and CPR: Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) Certification and at least one person trained in Pediatric First Aid and CPR must be present must be renewed every two years.

6.Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7.Qualifications: Educational background, training, and/or experience for each staff present must be available for review.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

NARRATIVE

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8. Immunization Requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles or influenza declination

9.Children’s Records: must be available for review; including but not limited to, the following: Name, address, and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

10.Staff Records: must be available for review; background clearance, LIC 503 Health Screening report, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, Staff Qualifications, LIC 9050 Employee Rights, LIC 501 Personnel Record, Mandated Child Abuse Certification, MMR, TDAP, TB, influenza, or influenza declination.

11. Isolation- When a child is ill, he/she shall be separated from other children, and remain separated.

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

13. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624).

14. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

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

Director Malkanthi Fernando was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. 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.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

NARRATIVE

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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services (IMS) policy was discussed with director Malkanthi. For IMS information see PIN 22-02CCP. 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 publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Director Malkanthi Fernando 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Title 22. One type B deficiency is being issued today for regulation 101216(g)(1)- (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. Please see attached LIC 809-D for citation. Due date September 14, 2025.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS DISCOVERY WORLD	FACILITY NUMBER: 364819492
	VISIT DATE: 08/14/2025

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	A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report and appeal rights were reviewed with director Malkanthi Fernando.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC809 (FAS) - (06/04)

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