Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455406573
Report Date: 06/10/2016
Date Signed: 06/10/2016 10:07:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SISCO, CRYSTAL FAMILY CHILD CARE HOMEFACILITY NUMBER:
455406573
ADMINISTRATOR:SISCO, CRYSTALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 710-5004
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:14CENSUS: 6DATE:
06/10/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Crystal SiscoTIME COMPLETED:
10:15 AM
NARRATIVE
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(3) A visit was made to the facility by LPA, Chris Archer. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently two adults living in the home.

During today’s visit the home and grounds were toured and the licensee was operating within the licensed capacity. Operating hours are 6am to 6pm, Mon–Fri. The floor plan was verified. Off limits areas are inaccessible. There is a working telephone in the home. The licensee stated the fireplace in the play room is never used and was blocked by toys during today's visit. The wood stove in the off-limits family room is inaccessible by gates. The licensee's pediatric CPR and First Aid expire 1/31/18. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisons are locked in the garage. There is a working smoke detector and fire extinguisher in the home. The licensee has a current roster of children in care and has conducted an emergency drill within the past six months. Firearms are locked and ammunition is locked separate. The children use the backyard as the outdoor play area and it is completely fenced. Children's records were reviewed. Some forms were missing from children's files. The licensee is not providing Incidental Medical Services – IMS at this time. All licensing reports are public information and must be made available upon request for at least three years.
Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D.

SUPERVISOR'S NAME: Jordan MonathTELEPHONE: (530) 895-5948-
LICENSING EVALUATOR NAME: Christen ArcherTELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SISCO, CRYSTAL FAMILY CHILD CARE HOME
FACILITY NUMBER: 455406573
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2016
Section Cited
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunization's as long as the child is enrolled.

Immunization records were missing for all 9 enrolled children that are not school aged.
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The licensee agreed to obtain immunization records for all 9 under school aged children and submit copies to Community Care Licensing (CCLD) by 6/24/16 as proof of correction.
Type B
06/24/2016
Section Cited
102419(d)(1)
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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A and keep documentation in the child's file.

LIC 995A was missing for all 17 enrolled children.
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The licensee agreed to obtain signed Parent's Rights LIC 995A for all 17 enrolled children and submit copies to CCLD by 6/24/16 as proof of correction
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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: Jordan MonathTELEPHONE: (530) 895-5948-
LICENSING EVALUATOR NAME: Christen ArcherTELEPHONE: (530) 895-4230
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2016
LIC809 (FAS) - (06/04)
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