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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619022
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:48:37 PM


Document Has Been Signed on 08/09/2022 01:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:PISTORIUS, DEANNE & SHANNONFACILITY NUMBER:
343619022
ADMINISTRATOR:PISTORIUS, DEANNE&SHANNONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 924-0454
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:14CENSUS: 12DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Deanne & Shannon PistoriusTIME COMPLETED:
02:15 PM
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On August 9, 2022 at approximately 1:00 PM, Licensing Program Analyst (LPA) Alize Tillery met with licensees Deanne & Shannon Pistorius for the purpose of an annual required 1 year inspection. The facility’s days and hours of operation are Monday - Friday from 7:30 AM to 4:30 PM. LPA observed care and supervision of 12 children supervised by both Licensee’s. All individuals subject to criminal background review have obtained a criminal record clearance. Licensee offers transportation services.

A health and safety evaluation was conducted in all areas accessible to children. Off limit areas consist of: right side of backyard, master bedroom and bathroom, bedroom #1 and office.

LPA observed a 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons in the home. Toxic and hazardous items are inaccessible to children, and safe toys were observed. LPA discussed current COVID19 guidelines with Licensee.

LPA reviewed all children’s files that were present. Children files were observed to be complete. Required postings and the children’s roster was observed. Licensee has record of conducting fire drills at least every six months. Per record, last drill was conducted on 07/18/2022. Licensee and all other adult files was observed to be complete. LPA observed licensee’s CPR and First Aid card which expires 12/27/2023. Licensee has workers insurance on file.

LPA discussed the requirement of renewing mandated reporter training every 2 years. Licensee’s Mandated Reporter Training is current and expires on 03/20/2023. LPA reviewed and provided the Family Child Care Home Entrance Checklist.

Continued on LIC809C…
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: PISTORIUS, DEANNE & SHANNON
FACILITY NUMBER: 343619022
VISIT DATE: 08/09/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitting 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: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee 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 licensee of the importance of checking for 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.

During today’s inspection, no deficiencies were observed. A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Deanne and Shannon Pistorius.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2