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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602062
Report Date: 05/28/2024
Date Signed: 07/08/2024 12:39:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20211007142526
FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 794-2889
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:0CENSUS: 0DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Licensee’s staff neglected resident’s incontinence care, contributing to infection.
-Licensee’s staff lacked the language skills needed to communicate with residents.
-Licensee did not maintain screen on sliding glass door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 01/23/2024 due to Licensee-Initiated Closure, the allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee’s staff neglected Resident #1’s (R1’s) incontinence care, contributing to R1 getting a urinary tract infection. The Complainant also alleged that Licensee’s staff lacked the language skills needed to communicate with residents in care, and that Licensee did not maintain a screen (meant to prevent insects coming in) on the facility’s sliding glass door which leads to the backyard. CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of relevant residents, facility staff, and outside sources. The Department also reviewed pertinent hospital, home health agency, skilled nursing, and facility care records.

[CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
VISIT DATE: 05/28/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

According to R1’s Admissions Agreement, since the time of their move-in, they had contracted Licensee for “Level 4 [of 5]” care, defined as “extensive care and assistance,” and which included, “Incontinency care, with frequent changes of briefs, possible showering, and nighttime changing.” According to the LIC603 Preplacement Appraisal which Licensee performed on R1 and corroborated by records from the skilled nursing facility (SNF) where R1 came from: R1’s underlying medical conditions included “progressive supranuclear palsy” (a neurological disorder impairing bodily movement), “high blood pressure,” recent “broken right forearm,” and history a broken hip. R1 also had “muscle weakness,” difficulty expressing themselves through speech, wore Depends for incontinence, and needed “lots of assistance in bathroom.” Interviews of facility management and multiple caregivers unanimously showed that residents who were deemed incontinent of bowel or bladder were supposed to have their Depends and/or briefs proactively checked (and if wet/soiled, changed) about once every hour.

Per interview of caregiver Staff #1 (S1): When they were first hired, Licensee told them that two (2) caregivers who had worked at the facility before S1 (and whose employment had since ended) did not check resident’s Depends often enough, and this included for R1. S1 said they were aware of R1 having Urinary Tract Infection (UTI) during the complaint allegation timeframe. Per interview of facility manager Staff #2 (S2): Licensee had since fired a few caregivers who had prior worked at the facility during the complaint allegation timeframe, because said staff did not timely change residents’ Depends/briefs, as evidenced by their “doubling up on Depends” (i.e., putting multiple layers of absorbent products on residents instead of changing the first one timely as designed) and using copious amount of “diaper rash creams” (instead of timely changing residents to protect their skin).

Hospital records, corroborated by home health records, showed: During late August 2021, R1 was transported to a local hospital’s Emergency Room (ER) after facility staff observed R1 having “burning with urination” and “brown crystals in [their] diaper.” Paramedics documented R1 initially had a fever of 101.1 F, low blood pressure in the “90s/60s” range, and “mild tachycardia” (i.e., elevated heartrate). The receiving ER physician wrote that R1 “presented in critical condition requiring constant attention,” because R1 was “septic” (i.e., infection had reached their bloodstream), “requiring aggressive resuscitation” with “potential for high morbidity/mortality.” The ER physician started R1 on intravenous antibiotics. [CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
VISIT DATE: 05/28/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3] The ER physician subsequently wrote that while R1 indeed had “foul smelling urine,” the “brown fine crystals” which facility staff saw “appear to [instead] be part of [R1’s] diaper which is broken.” Blood and urine culture testing at the hospital showed that the cause of R1’s sepsis was a urinary tract infection (UTI), caused by the bacterium Klebsiella pneumoniae. Per hospital and home health records, R1’s body temperature and blood pressure soon returned to normal ranges, antibiotics helped R1 successfully recover, and there was no evidence of skin breakdown on R1’s body.

According to the federal National Institutes of Health (NIH): Good personal hygiene (e.g., timely changing of soiled Depends and cleaning with wet wipes) is a primary preventative factor for UTIs in the elderly. Also, the bacterium Klebsiella pneumoniae typically colonizes the gastrointestinal tract, but can be inadvertently introduced into the urinary tract. According to ParentGiving.com, a major online retailer of adult continence supplies: Sodium polyacrylates are very long and curly chains of molecules that stretch out when exposed to liquids. Adult disposable diapers rely on sodium polyacrylate powders woven into cotton fibers. As they trap and lock away urine from the wearer’s skin, the powder granules turn into translucent hydrogels. An adult diaper can absorb up to 40 oz of liquid but can also disintegrate after becoming fully saturated with urine.

Based on LPA observation and interviews, during the complaint allegation timeframe, every resident in care spoke English but none spoke Spanish. LPA visited the facility on 07/01/2021, encountering Staff #3 (S3) as the only staff on duty. S3 spoke Spanish but was unable to converse in English. For the current complaint investigation: LPA returned to the facility on 10/12/2021, finding that one of two staff on duty, S1, spoke Spanish but was unable to converse in English. LPA returned to the facility on 02/28/2022, finding that Staff #4 (S4), who was the only staff on duty, spoke Spanish but was unable to converse in English.

Interview of facility manager confirmed: During the complaint allegation timeframe, there was initially no screen on the sliding glass door leading from the facility’s dining room to the facility’s back yard. The were three (3) days when the facility’s central air conditioning (AC) was non-working; during this time, staff kept the sliding glass door ajar so that fresh air could come inside. The lack of a screen in this location allowed some flies to enter the facility. On Day 2 of the AC outage, License arranged for a contractor/vendor to come install a screen over this door, remedying the problem. During LPA’s subsequent 10/12/2021 site visit, he observed intact screens over this sliding glass door and each of the bedroom windows.

[CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
VISIT DATE: 05/28/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3]

Based on records and interviews, a preponderance of evidence exists to show that Licensee’s staff neglected R1’s incontinence care, contributing to infection. A preponderance of evidence also exists to show that Licensee employed direct care staff who lacked the language skills needed to communicate with residents in care, and that Licensee did not initially have a screen over its sliding glass door. The above allegations are therefore Substantiated. Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages).

The Department determined that one of the violations resulted in short-term illness to a resident in care (requiring a brief hospital visit), but did not result in long-term injury. An Immediate Civil Penalty of $500.00 was thus charged and is noted on the LIC421-IM page. Since the facility has closed and ceased operations, no Plans of Correction were formed with the Licensee.

A copy of this report, the LIC9099-D pages, the LIC421-IM page, and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2024
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: …(3) Ensuring that incontinent residents are kept clean and dry…” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records review and interviews, Licensee did not ensure that 1 of 4 residents (R1), who was known to be incontinent, was kept clean and dry. This posed an immediate health risk to persons in care.
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Type B
05/28/2024
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements – General: “(d) All personnel shall…have...: (3) Skill and knowledge required to provide necessary care and supervision, including the ability to communicate with residents.” The requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on interviews and LPA observation, Licensee did not ensure that all personnel had the skill and knowledge required to provide necessary care and supervision, including the ability to communicate with 4 of 4 residents (R1 through Resident #4). This posed a potential personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
87303(c)
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87303 Maintenance and Operation: “(c) All window screens shall be clean and maintained in good repair.” This requirement was not met, as evidenced by:
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By the time of CCLD’s investigation, Licensee had installed the screen over its sliding glass door. This action resolved the deficiency.
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Based on records review and interviews: There was a period when Licensee did not maintain a window screen on the facility’s sliding glass door, as required. This posed a potential health risk to 4 of 4 residents (R1 through Resident #4) in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20211007142526

FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 794-2889
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:0CENSUS: 0DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Licensee did not provide residents the required quantity of food.
-Licensee did not provide residents the required quality of food.
-Licensee did not handle perishable foods in a safe manner.
-Licensee’s staff lacked required knowledge related to resident food service.
-Licensee did not maintain a comfortable temperature for residents, as required.
-Licensee did not post a current facility license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 01/23/2024 due to Licensee-Initiated Closure, the allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee did not serve residents with food of the quality and quantity needed to meet their nutritional needs, that Licensee’s staff did not handle perishable foods in a safe manner, and that Licensee’s staff lacked required knowledge related to resident food service. The Complainant also alleged that Licensee did not maintain a comfortable temperature for residents inside the facility, and that Licensee did not post for viewing its current facility license. CCLD’s investigation involved multiple unannounced facility tours during mealtimes and interviews of relevant residents, facility staff, and outside sources. The Department also reviewed a pertinent vendor/contractor invoice.

[CONTINUED ON LIC 9099-C, 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
VISIT DATE: 05/28/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-A] During multiple site visits to the facility (both during the complaint allegation timeframe and after the complaint was received), LPA observed staff cook/prepare and serve meals to the residents in care. Staff washed their hands before cooking, rinsed vegetables under running water, and practiced safe food handling and storage practices. The food served was home-cooked using healthful, fresh ingredients. The meals were presentable and nutritionally balanced. Staff cooked large enough quantities such that multiple portions were left over. Staff interviews showed they were mindful to include vegetables, carbohydrates, and proteins when preparing a meal, and they confirmed any resident could have second servings if they wished. In their own interviews, residents confirmed the food served to them was tasteful and plentiful.

LPA inspected the facility’s refrigerator/freezer and dry storage closet, finding that there was at least two (2) days-worth of perishable food and at least seven (7) days-worth of non-perishable food present at the facility. There were no foods present beyond their printed expiration date, and no foods appearing spoiled. All perishable foods, to include meats/proteins and opened items requiring refrigeration, were correctly covered and cold-stored when not in active use by staff. LPA measured the temperature of the facility’s refrigerator and its freezer, finding both were within the required ranges. Per interview of the facility administrator, all new hires start out accompanying an experienced coworker for on-the-job training, which includes the new hire demonstrating how they prepare breakfast, lunch, and dinner. Interviews of frontline caregivers revealed that many staff had several years of hands-on, home-cooking experience even before they applied to work at the facility.

The Complainant alleged that the facility’s central air conditioning (AC) was out-of-service for more than seven (7) days during Summer 2021. However, facility manager and staff interviews showed that the AC was impacted for three (3) days in total. Upon the AC system going down, the facility manager timely contacted an AC-repair contractor/vendor (i.e., Day 1), securing the next available appointment for Day 2. The vendor was onsite Day 2 to start the repair but needed to return on Day 3 for additional work. The vendor fully remedied the system by Day 3. LPA obtained a copy of the paid invoice as verification. Interviews of the Complainant, facility manager, and frontline caregivers unanimously showed: During the time the facility’s AC was down, Licensee’s staff set up multiple portable electric fans inside the facility, which were effective at keeping residents cool. Due to their baseline memory-loss, none of residents who were in care at the time CCLD conducted its investigation could reliably comment about the days when the AC was down. [CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 08-AS-20211007142526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062
VISIT DATE: 05/28/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Over multiple site visits to the facility (both during the complaint allegation timeframe and after the complaint was received), LPA observed that the facility’s current (i.e., meaning not expired, rescinded, or superseded) CCLD-issued license was consistently posted in the facility’s common area, readily viewable any visitor. Manager interview confirmed that at no point was the facility’s license taken down, or not posted, during the complaint allegation time frame.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not serve residents with food of the quality and quantity needed to meet their nutritional needs, that Licensee’s staff did not handle perishable foods in a safe manner, that Licensee’s staff lacked required knowledge related to resident food service, that Licensee did not maintain a comfortable temperature for residents inside the facility, or that Licensee did not post for viewing its current facility license. These allegations are therefore Unsubstantiated, and no deficiencies were cited for them.

A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9