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17 - 388093 <br /> Secretary of State <br /> i Statement of Information LLC-12 FILED <br /> (Limited Liability Company) Secretary of State <br /> CtIFOAN� <br /> State of California <br /> IMPORTANT—Read instructions before completing this form. JAN 3 Q 2017 <br /> Filing Fee-$20.00 <br /> Copy Fees-Face Page$1.00& .50 for each attachment page; <br /> //- <br /> Certification Fee-$5.00 <br /> This Space For Office Use Only <br /> 1. Limited Liability Company Name <br /> Dycora Transitional Health -- Quail lake LLC <br /> 2. 12-Digit Secretary of State File Number 3. State or Place of Organization(only if formed outside of California) <br /> 201630510290 <br /> 4. Business Addresses <br /> a Street Address of Principal Office-Do not list a P.O.Box City(no abbreviations) Stale Zip Code <br /> 122.1 Rose Marie Lane Stockton CA 95207 <br /> b.Mailing Address of LLC,if different than item 4a City(no abbreviations) State Zip Code <br /> c.Street Address of Califomia Office,if Item 4a is not in California-Do not list a P 0 Box City(no abbreviations) State Zip Code <br /> CA <br /> If no managers have been appointed or elected, provide the name and address of each member At least one name and address <br /> 5. Manager(s)or Member(s) must be listed.If the managerlmember is an individual,complete Items 5a and 5c(leave Item 5b blank) If the manager/member is an <br /> entity,complete Items 5b and 5c(leave Item 5a blank) Note: The LLC cannot serve as its own manager or member. If the LLC has <br /> additional managers/members,enter the name(s)and addresses on Form LLC-12A(see instructions). <br /> a.First Name,if an individual-Do not complete Item 5b Middle Name Last Name Suffix <br /> b.Entity Name-Do not complete Item 5a <br /> Cass Enterprises LLC <br /> c.Address City(no abbreviations) State I Zip Code <br /> 650 West Alluvial Avenue Fresno CA 93711 <br /> 6. Agent for Service of Item 6a and 6b:If the agent is an individual,the agent must reside in California and Item 6a and 6b must be completed with the <br /> Process agent's name and California address Item 6c: If the agent is a California Registered Corporate Agent,a current agent registration <br /> certificate must be on file with the California Sec etary of State and Item 6c must be completed leave Item 6a-6b blank). <br /> a.California Agent's First Name(if agent is not a corporation) Middle Name Last Name Suffix <br /> Elizabeth Plott Tyler <br /> b Street Address(if agent is not a corporation)-Do not list a P.O.Box City(no abbreviations) State Zip Code <br /> 5455 Wilshire Boulevard, Suite 1925 Los Angeles CA 90036 <br /> c.California Registered Corporate Agent's Name(if agent is a corporation)—Do not complete item 6a or 6b <br /> 7. Type of Business <br /> a.Describe the type of business or services Of ine u1-n1t8a La!3iiity Company <br /> Provider support <br /> 8. Chief Executive Officer,if elected or appointed <br /> a.First Name Middle Name last Name Suffix <br /> b.Address City(no abbreviations) State Zip Code <br /> 9, The Information contained herein,including any attachments,is true and correct. <br /> 01/23/17 Elizabeth Plott Tyler Attorney ./ <br /> Date Type or Print Name of Person Completing the Form Title Si <br /> Return Address(Optional)(For communication from the Secretary of State related to this document,or if purchasing a copy of the filed document enter the name of a <br /> person or company and the mailing address.This information will become public when filed. SEE INSTRUCTIONS BEFORE COMPLETING.) <br /> Name: r Elizabeth Plott Tyler 7 <br /> Company: Tyler &Wilson LLP <br /> Address: 5455 Wilshire Boulevard, Suite 1925 <br /> City/State/Zip: L Los Angeles, CA 90036 <br /> LLC-12(REV 0712016) / 2016 California Secretary of State <br /> www.sos.ca.aov1business/be <br />