<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004973
Report Date: 06/11/2026
Date Signed: 06/11/2026 02:40:59 PM

Document Has Been Signed on 06/11/2026 02:40 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GUTIERREZ-PONCE, ELIZABETHFACILITY NUMBER:
414004973
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ-PONCE, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 346-6687
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
06/11/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Magda OlivaresTIME VISIT/
INSPECTION COMPLETED:
03:05 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 June 11, 2026, at approximately 8:30 am, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection. Licensee was not present in the home during entirety of today’s visit; licensee has been out for a couple of day due to family emergency. Type B citation was issued for this deficiency. LPA met with assistant Yenifer Samayoa and explained purpose of the inspection visit. At approximately 9:25am, facility representative Magda Olivares (facility #414001261) arrived at the home. Present during today’s visit was facility representative and two assistants caring for 7 children (3 infants and 4 preschoolers). LPA observed facility representative to not have criminal background clearance or associated with facility; a type A deficiency was issued as this poses and immediate health and safety hazard to children in care. Facility is in compliance with ratio capacity requirements. Daycare hours of operation are Monday – Friday from 7:30 am to 5:00 pm.

LPA observed Childcare License, Parent's rights and Earthquake Preparedness Checklist posted and is easily visible to parents. Emergency Disaster Plan (LIC610A) was available for review in facility binder. Per facility representative, last emergency drill was conducted on January 16, 2026, LPA reminded facility representative to properly document disaster drill for LPA review, technical assistance provided.

LPA observed a pull-down fire alarm in living room. A fully charged fire extinguisher was observed on hallway wall by kitchen and is easily accessible. Per facility representative, home is equipped with a fully stocked first aid kit. Smoke detector and carbon monoxide detectors were tested during today’s visit and observed to be in working condition. Per facility representative families contact facility representative when Licensee is unavailable. Per facility representative, there are no weapons or firearms in the home.

LPA inspected the indoors and outdoors of home for health and safety hazards. LPA observed home to be free of defects or conditions that might endanger a child. Home is a one-story dwelling, with 2 bedrooms and 1 bathroom. Daycare areas are: Living room, hallways, dining room, bedroom #1, shade room and a portion of the backyard. Off-limit areas are: Master bedroom (2), garage, and a portion of backyard. Isolation area: Sick children will be isolated in the living room and away from other children. The home has proper heating, lighting and ventilation to provide safety and comfort. LPA observed age-appropriate toys, puzzles, a blocked off area for infants in living room, learning materials and books, all in good condition. LPA observed cubbies for children to store their personal belongings.

Cont. page 2...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2026
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 13
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)
Page: 2 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973
VISIT DATE: 06/11/2026
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
Page 2...

LPA observed serval child safety gates installed at both entrances to kitchen, living room and dining room. LPA observed kitchen cabinets are secured with childproof latches. Fireplace in living room is properly barricaded and made inaccessible to children. LPA reminded assistant to secure all electrical outlets with childproof covers. LPA observed rugs and foam mats in the daycare area to absorb and cushion falls.

Bathroom was clean and cabinet was secured with a childproof latch. LPA observed a stepping stool for children to use sink and potty-training chairs. Cleaning supplies and other potentially harmful items are stored inaccessible to children and behind child proof cabinets. A changing table was observed in hallway outside bathroom which was equipped with children diapering supplies.

LPA observed playpens and sleeping cots for napping purposes. Playpens are used by infants for napping purposes. Playpen mattresses were firm, per assistant fitting sheets are attached to mattress when infants are put down to nap. During naptime, LPA observed fitted sheet to be dislodged and infant holding sheet, technical violation issued. Foldable sleeping cots are available for older children and LPA observed foldable cots to be in good condition. Facility provides sheets for playpens and cots and are washed weekly or as needed. LPA reviewed 15-minute sleep logs for all enrolled infants, sleep logs are maintained and up to date.

LPA observed the backyard enclosed and surrounded by a 5 ft wood fence and child proof gates surrounded and secured on limits portion of backyard. LPA observed a playhouse, ride on toys, slide play structure and other age-appropriate outdoor toys, all in good condition. Flooring in backyard is artificial grass to cushion falls. LPA did not observe any pool, spas, or other bodies of water.

Per facility representative Magda Olivares, licensee, provides meals for children in care, which includes breakfast, lunch and pm snacks. LPA reminded facility representative that any food brought from home must be labeled and stored properly. LPA observed highchairs and child size table and chairs for child to sit and eat. LPA observed kitchen to be clean, and food properly stored to avoid contamination or spoilage.

LPA reviewed 9 children’s files and 2 staff files; 2 children’s files were missing immunization records, and one staff member (A2) was missing MMR vaccine, two type B deficiency were issued. Technical assistance was provided for missing yearly Flu vaccine or Flu vaccine declination. Children’s files included PM286 used for updating vaccine record and LIC282. LPA reviewed children’s roster, which is maintained up to date. LPA observed Licensee’s CPR/FA expiration date is 12/2027 and licensee’s Mandated reporter expires 04/2027.

Cont. page 3...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 12 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973
VISIT DATE: 06/11/2026
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
Page 3...

Facility representative Magda Olivares was reminded that all adults 18 and over living or working in the home, 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 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.

LPA discussed the safe sleep regulations with facility representative Magda Olivares 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 facility representative, Magda Olivares of the importance of checking for and removing any 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.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Facility representative Magda Olivares 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.

Facility representative Magda Olivares was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensee.

Cont. page 4...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 13 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973
VISIT DATE: 06/11/2026
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
Page 4...

During the exit interview, the facility representative Magda Olivares, 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 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.

LPA Maria Olguin-Leon informed facility representative, Magda Olivares, that this report dated June 11, 2026, documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, Maria Olguin-Leon informed facility representative Magda Olivares to provide a copy of this licensing report dated June 11, 2026 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See page LIC809D for deficiencies cited today under CCR, Title 22, Div. 12, Chapt. 1.

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

Exit interview was conducted and report was reviewed and translated into Spanish to facility representative, Magda Olivares. Appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 06/11/2026 02:40 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 06/11/2026 at 01:18 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in facility representative did not have criminal background clearance and associated to facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2026
Plan of Correction
1
2
3
4
Facility representative will no longer be available to substitute at facility, during Licensee's absence.
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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 06/11/2026 02:40 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 06/11/2026 at 01:18 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee was not present during the entirety of today's visit and has been gone for the last couple of days and will be returning tonight.
POC Due Date: 06/15/2026
Plan of Correction
1
2
3
4
Licensee will review temporary absence regulation regarding absence not to exceed 20 percent of the hours that licensee is providing care and will submit written statement to LPA indicate Licensee understand regulation. Licensee will also develop a written plan stating that Licensee understands that licensed providers cannot be substitutes when licensee is not present. Licensee will email to LPA by POC due date.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in A2 was missing MMR vaccine, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2026
Plan of Correction
1
2
3
4
A2 will visit health clinic for antibodies for MMR vaccine or MMR vaccine, Licensee will email results to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 06/11/2026 02:40 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 06/11/2026 at 01:18 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GUTIERREZ-PONCE, ELIZABETH
FACILITY NUMBER: 414004973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 of 9 children were missing immunization records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
1
2
3
4
Licensee will collect immunization records for the two missing children and will email to LPA by POC 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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Maria Olguin-Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 13