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Att C - CDSS Evaluations

Signal Hill City Council
January 9, 2024

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Att C - CDSS Evaluations
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January 9, 2024
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Department of

SOCIAL SERVICES
Community Care Licensing

FACILITY EVALUATION REPORT
Facility Number: 198601767
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:19:11 PM
Document Has Been Signed on 07/06/2023 03:19 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
EL SEGUNDO, 1000 CORPORATE DR #100 MONTEREY PARK, CA 91754 FACILITY NAME: COLE VOCATIONAL SERVICES SIGNAL HILL FACILITY NUMBER:
198601767
ADMINISTRATOR:PORTER, LASONJA FACILITY TYPE: 775
ADDRESS: 2798 JUNIPERO AVE TELEPHONE: (562) 912-7340
CITY: SIGNAL HILL STATE: CA ZIP CODE: 90755
CAPACITY: 30 CENSUS: 61 DATE: 07/06/2023
TYPE OF VISIT: Required - 1 Year UNANNOUNCEDTIME BEGAN: 11:17 AM MET WITH: Director Aniece J. Johnson TIME
COMPLETED: 03:15 PM

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25 On 07/06/23 Licensing Program Analysts (LPA) Lizeth Villegas made an unannounced visit to the Cole Vocational Services Signal Hill and met with Director Aniece J. Johnson as the purpose of today's visit was explained. The facility profile shows that the facility is licensed to serve 30 non-ambulatory developmentally disabled adults, program hours are from 8:00 AM- 12:00 PM and from 1:00 PM to 5:00 PM. Cole Vocational Services Signal Hill does not provide transportation. Consumers are linked to the Harbor Regional center, the staff to consumer ratio is 1 one staff to 3 three consumers.

As a part of today's inspection LPA reviewed 6 consumer records, 2 staff records and inspected the physical plant.

This is a day program located in one large building consisting of the following: Activity/game Room, Computer Room, Art Room, style Room, Nurse Station, Sensory Room, Changing Room, Kitchen, Storage/lockers and administrative offices. There is a LVN on premises that gives clients medications as prescribed. LPA observed sufficient furniture and lighting throughout the facility, walls and floors were in good condition, walkways throughout the day program and all exits were clear of hazards and debris. The facilities kitchen appears to be clean and well maintained, consumers bring their own meals and program provides snacks only.

Program Director stated there are sixteen (16) restricted health care conditions consumers, twelve (12) consumers use a G-tube and four (4) do not, restricted health care plans are in consumers files. The last disaster drill was conducted 06/20/23 and a Disaster Plan was on file. The last inspection held by the fire department was on 12/2022, two (2) Fire extinguishers were properly charged, and the first aid kit was available and fully stocked.

During today’s visit no discrepancies were observed. Exit interview conducted with Director Aniece J. Johnson and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond TELEPHONE: (323) 981-3328 LICENSING EVALUATOR NAME: Lizeth Villegas TELEPHONE: (323) 981-1755 LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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 1
Attachment C
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Department of

SOCIAL SERVICES
Community Care Licensing

FACILITY EVALUATION REPORT
Facility Number: 198603362
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:15:31 PM
Document Has Been Signed on 03/22/2023 02:15 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
EL SEGUNDO, 1000 CORPORATE DR #100 MONTEREY PARK, CA 91754 FACILITY NAME: DUNGARVIN CALIFORNIA - SIGNAL HILL FACILITY NUMBER:
198603362
ADMINISTRATOR:MARTIN, ALLISON FACILITY TYPE: 775
ADDRESS: 695 EAST 27TH STREET TELEPHONE: (510) 727-9448 CITY: SIGNAL HILL STATE: CA ZIP CODE: 90755
CAPACITY: 30 CENSUS: 11 DATE: 03/22/2023
TYPE OF VISIT: Case Management - Incident UNANNOUNCEDTIME BEGAN: 12:48 PM MET WITH: Beverly Ruiz, Program Director TIME
COMPLETED: 02:19 PM

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25 On 3/22/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Case Management inspection. LPA met with Beverly Ruiz , Program Director to interview about the events of 2/28/23. The purpose of today's visit involved gathering additional details surrounding the death of Client #1 which occurred on February 28, 2023.

During the visit LPA reviewed Client #1's file and requested copies of supportive documents (Most current IPP, departure sign-out chart via Reliable Transport on 2/28/23 and the contact number and Driver's first name). The facility has provided CCLD with the necessary documents requested, and has completed a Death report and SIR within the required time frame.

Investigation:

LPA interviewed Beverly Ruiz regarding Client #1's day and departure events as well as any abnormalities.

SUPERVISOR'S NAME: Ulysses Coronel TELEPHONE: (323) 400-7397 LICENSING EVALUATOR NAME: Mario Leon TELEPHONE: (323) 981-1755 LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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 1
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Department of

SOCIAL SERVICES
Community Care Licensing

FACILITY EVALUATION REPORT
Facility Number: 198603362
Report Date: 08/31/2023
Date Signed: 09/01/2023 09:21:16 AM
Document Has Been Signed on 09/01/2023 09:21 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
EL SEGUNDO, 1000 CORPORATE DR #100 MONTEREY PARK, CA 91754 FACILITY NAME: DUNGARVIN CALIFORNIA - SIGNAL HILL FACILITY NUMBER:
198603362
ADMINISTRATOR:MARTIN, ALLISON FACILITY TYPE: 775
ADDRESS: 695 EAST 27TH STREET TELEPHONE: (510) 727-9448 CITY: SIGNAL HILL STATE: CA ZIP CODE: 90755
CAPACITY: 30 CENSUS: 30 DATE: 08/31/2023
TYPE OF VISIT: Required - 1 Year UNANNOUNCEDTIME BEGAN: 10:06 AM MET WITH: Program Director Beverly Ruiz TIME
COMPLETED: 12:45 PM

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25 On 08/31/23 Licensing Program Analysts (LPA) Lizeth Villegas made an unannounced visit to the Dungarvin California-Signal Hill and met with Program Director Beverly Ruiz as the purpose of today's visit was explained.

The facility is licensed for a capacity of 30 adults ages 18-59 of which 10 may be non-ambulatory. 18 consumers are at the day program in the morning and 12 consumers in the afternoon. Day program consumers are linked to the Harbor Regional center, the staff to consumer ratio is one (1) staff to three (3) consumers.

As a part of today's inspection LPA reviewed two (3) consumer records, two (2) staff records and inspected the physical plant. The property consists of (1) large building which includes a garden room, music room, art room, tech room offices, Life skills room, gaming room, exercise room, library, conference room, administrative offices, kitchen, (3) unisex bathrooms and an outside patio. The Facility walls and floors were in good condition, adequate lighting. Plenty of storage space, chemicals and sharps were properly locked. The restrooms were clean and within Title 22 regulations. Landline observed, smoke alarms and carbon monoxide are hardwired and operational. LPA observed sufficient furniture and lighting throughout the facility, walkways throughout the day program and all exits were clear of hazards and debris. Consumers bring their own meals and program provides snacks only, no medication is administered at day program.

The last disaster drill was conducted 08/07/23 and a Disaster Plan was on file. The last inspection held by the Los Angeles fire department was on 04/23/2023, three (3) Fire extinguishers were properly charged, and the first aid kit was available and fully stocked.

During today’s visit no discrepancies were observed. Exit interview conducted with Program Director Beverly Ruiz and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond TELEPHONE: (323) 981-3328 LICENSING EVALUATOR NAME: Lizeth Villegas TELEPHONE: (323) 981-1755 LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 1
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Department of

SOCIAL SERVICES
Community Care Licensing

FACILITY EVALUATION REPORT
Facility Number: 198010585
Report Date: 07/12/2023
Date Signed: 07/19/2023 07:42:39 AM
Document Has Been Signed on 07/19/2023 07:42 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
CCLD Regional Office, 1000 CORPORATE
CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH COMMUNITY IMPROVEMENT
LEAGUE

FACILITY
NUMBER:
198010585
ADMINISTRATOR:LAURA SIDNEY FACILITY TYPE: 840
ADDRESS: 2399 CALIFORNIA AVENUE,SUITE A TELEPHONE: (562) 951-3500 CITY: SIGNAL HILL STATE: CA ZIP CODE: 90755
CAPACITY: 29 CENSUS: 1 DATE: 07/12/2023
TYPE OF VISIT: Required - 1 Year UNANNOUNCEDTIME BEGAN: 11:15 AM MET WITH: Dr. Farah Khaleghi, Executive Director and Laura Sydney, Director
TIME
COMPLETED: 12:45 PM

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25 Licensing Program Analyst (LPA) Dayna Chambers conducted an unannounced annual inspection on July 12, 2023, at 11:40AM. LPA met with Dr.Farah Khaleghi, Executive Director, who guided analyst on a tour of the facility. This is a school age program which consists of 1 classroom; RM#E. Facility operation hours are Monday to Friday from 7:00am to 6:00pm. This center follows Title 22 and Title 5 regulations.

All areas identified on the Facility Sketch were inspected. Also present was Laura Sydney, Site Director.

Upon arrival, the following staff were present during this inspection: The center is experiencing low enrollment stats. RM# E- Staff #1 with 1 school age child. The facility was observed to be within the license capacity and limitations. The following was observed during the tour of the facility: Furniture and equipment were inspected for age appropriateness and in good repair. Telephone service, heating, lighting, and ventilation were evaluated. Children have their own cubby to store their belongings. The center has a laundry room and linens are washed by the center weekly and as needed. Napping equipment (mats) were observed in a separate storage area in room. Per director, the isolation area is in the office. Age-appropriate sinks and toilets were inspected for availability and good repair in all restrooms. General sanitation was observed. Availability of indoor drinking water was observed in classrooms. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Director states that poisons are locked in the inaccessible storage room. Carbon monoxide detectors were observed and are operable. All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal. Outdoor playground equipment is in a safe condition, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free There are no firearms stored on the premises. There are no pools or bodies of water at the facility. All individuals present have SUPERVISOR'S NAME: Valarie Cook TELEPHONE: (323) 513-3858 LICENSING EVALUATOR NAME: Dayna Chambers TELEPHONE: (323) 558-2962 LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL

SERVICES

COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE
CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH COMMUNITY

IMPROVEMENT LEAGUE
FACILITY NUMBER: 198010585
VISIT DATE: 07/12/2023

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obtained a criminal record clearance or criminal record exemption. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. Children’s Records were reviewed. (The name, address, and telephone number of child’s authorized representative is on file) and medical Assessment.) for completeness; Inspection of required forms was made and documented on the LIC 857. LPA also reviewed staff records. The review of Staff records was documented on the LIC 859. Staff present did have proof of the AB 1207 Mandated Reporter Training certificate on file. Staff present did have proof against MMR, TDAP, TB Clearance, and current influenza/or declination of influenza. All staff have been given on the-job training sanitation principles, housekeeping, including universal health precautions. LPA also issued the Review of Staff records (LIC 859) to the licensee during this inspection. The LIC 857 and the LIC 859 documents the staff and children’s files that were reviewed during this inspection. Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Children present were signed in. Disaster drill log was available, last drill was conducted on June 30, 2023. Menus are posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. Snacks were reviewed for availability, quantity, and appropriateness to children in care. The facility provides Breakfast, AM Snack, Lunch, and PM snack. First Aid supplies were observed in the classroom in the cupboards. According to Director, medication is only administered to a child when accompanied with a doctor's note and is stored in the office. The facility was observed to be equipped with an isolation area for any child who becomes ill, and it is in the office. Director states they have an IMS statement. 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 [email protected]. 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. Director 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. CCC COMPLETED TESTING on 12/13/2022 AND NO LEAD EXCEEDANCES: 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
SUPERVISOR'S NAME: Valarie Cook TELEPHONE: (323) 513-3858 LICENSING EVALUATOR NAME: Dayna Chambers TELEPHONE: (323) 558-2962 LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
LIC809 (FAS) - (06/04) Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL

SERVICES

COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE
CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH COMMUNITY

IMPROVEMENT LEAGUE
FACILITY NUMBER: 198010585
VISIT DATE: 07/12/2023

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test. For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance with the Written Directives outlined in PIN 21-

21.1-CCP.

LPA referred Director to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.

For IMS information see PIN 22-02-CCP. 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-carecenters/.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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

Exit interview conducted and report was reviewed with the Director Laura Sydney.

There were no deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Valarie Cook TELEPHONE: (323) 513-3858 LICENSING EVALUATOR NAME: Dayna Chambers TELEPHONE: (323) 558-2962 LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
LIC809 (FAS) - (06/04) Page: 3 of 3
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Department of

SOCIAL SERVICES
Community Care Licensing

FACILITY EVALUATION REPORT
Facility Number: 197803342
Report Date: 10/02/2023
Date Signed: 10/02/2023 04:08:32 PM
Document Has Been Signed on 10/02/2023 04:08 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: UNLIMITED QUEST INC LONG BEACH FACILITY
NUMBER:
197803342
ADMINISTRATOR:JOSEPHINE SANTOS FACILITY TYPE: 775
ADDRESS: 3350 OLIVE AVE TELEPHONE: (562) 595-0730
CITY: SIGNAL HILL STATE: CA ZIP CODE: 90807
CAPACITY: 45 CENSUS: 44 DATE: 10/02/2023
TYPE OF VISIT: Required - 1 Year UNANNOUNCEDTIME BEGAN: 09:12 AM MET WITH: Josephine Santos, Administrator TIME
COMPLETED: 04:28 PM

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25 On 10/02/2023 at 09:00 AM Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit using the CARES tool. LPA was met by Administrator, Josephine Santos (S1), and the purpose of today’s visit was explained. The facility is licensed to serve 45 adult clients with behavioral issues.

There are currently fourty-four (44) clients in care, all clients are ambulatory. The facility is a 1-story structure with 10 rooms and 5 bathrooms, activity room. kitchen and work out room, teaching rooms, computer room and staff offices.

LPA and Administrator toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked and are in good condition and well maintained. LPA noted adequate lighting was provided to staff and clients, storage for client personal belongings was observed. Walls and floors were in good repair. All equipment, computers, work stations are well maintained and there was adequate PPE stocked at the time of visit. LPA observed Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA noted the following:

Bathrooms #1-5 hot water temperature properly measured between 105 and 120 degrees Fahrenheit.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. The facilities’ last fire drill was conducted by eighteen (18) clients and eight (8) staff on 09/07/23 at 10:32AM. LPA observed 18 Smoke detectors, all detectors were individual with proper battery supply. Four (4) working Carbon Monoxide detectors were found in the facility. The facility's four (4) Fire Extinguishers were checked and found to be fully charged as of 08/07/23 and all were accessible.

Three (3) clients files were reviewed and found to be complete. LPA reviewed two (2) client’s medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. The facility does not handle client’s money/cash resources. All the required documents are posted in the facility in a visible area to staff and clients.

Report continues, see LIC809C
SUPERVISOR'S NAME: Ulysses Coronel TELEPHONE: (323) 981-1755 LICENSING EVALUATOR NAME: Mario Leon TELEPHONE: (323) 981-1755 LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL

SERVICES

COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: UNLIMITED QUEST INC LONG BEACH FACILITY NUMBER: 197803342 VISIT DATE: 10/02/2023

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During the visit, LPA observed the facility infection control practices. LPA did observe screening protocols for visitors, staff and clients, sanitizing stations (Located in common areas and restrooms).

LPA observed a resting room and an isolation room, if necessary, for a client. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID19 guidance.

During today’s visit there were no deficiencies cited under California code of regulation title 22, division 6, chapter 8. One (1) Technical Assistance note was provided, see LIC9102-AN.

An exit interview was held with Administrator, Josephine Santos, and copy of the report was provided.

SUPERVISOR'S NAME: Ulysses Coronel TELEPHONE: (323) 981-1755 LICENSING EVALUATOR NAME: Mario Leon TELEPHONE: (323) 981-1755 LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
LIC809 (FAS) - (06/04) Page: 2 of 3

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