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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 12/08/2021
Date Signed: 12/08/2021 03:18:09 PM

Document Has Been Signed on 12/08/2021 03:18 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BAUSLEY, JACKIELYN FCCHFACILITY NUMBER:
493009498
ADMINISTRATOR:BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jackeilyn BausleyTIME COMPLETED:
03:30 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. 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. 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.

At 9:45am the home was toured inside and outside. The licensee and 3 assistants, (A1, A2 and A3) were supervising 9 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 12:00AM-11:59PM, Monday–Friday. During the inspection Licensee (L1) submited an updated LIC279 to LPA Strother, updating the hours of operation. L1 stated that she understands that no one child can be in care for a 24 hour period. The floor plan submitted by the licensee was reviewed and updated by L1 during the inspection to include the kitchen as off-limits. The off-limits areas of the home are the entire upstairs level of the home, the garage, and the kitchen. Upstairs and the kitchen are made inaccessible by child safety gates and a lock is on the garage door. The home was observed to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire 12/2021. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be accessible to children and not stored out of the reach of children. At 10:04am LPA observed an unlocked cabinet under the bathroom sink that contained the following, jugs of bleach, floor cleaner, hand sanitizer and lysol spray. The fireplace is barricaded and has been made inaccessible. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 6/2021.

Continue on LIC812-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498
VISIT DATE: 12/08/2021
NARRATIVE
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The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. Licensee stated that poisons are stored in the garage. The garage is locked with a dead bolt requiring a key to open. The children use the backyard as the outdoor play area, and it is fully fenced. LPA observed a trampoline in the backyard that was in disrepair. The trampoline accessible to children in the backyard has cracked plastic around the base of the trampoline and the fabric covering the springs was observed to be torn and worn away in many areas around the equipment. There were no pools or other bodies of water observed in the yard. Ten children's records were reviewed during the inspection. Files contained the required documents. Facility and personnel files were reviewed. Licensee and assistant, Adult 1 (A1) do not have current Mandated Reporter Training Certificates on file. L1's training expired on 04/19/21 and A1's expired 08/27/21. L1 stated that she and A1 have not renewed their certificates this year.

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. Licensee did not have a safe sleep log on file for three children under age 2, C1, C2 and C3.

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 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: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Jackielyn Bausley. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Continue on LIC809-C(2)

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2021 03:18 PM - It Cannot Be Edited


Created By: Amy Strother On 12/08/2021 at 02:07 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BAUSLEY, JACKIELYN FCCH

FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. At 10:04am LPA observed the bathroom cabinet below sink was accessible to children. The cabinet contained jugs of bleach, hand snaitizer, carpet cleaner and other various products used for cleaning. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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Licensee removed all cleaning products from under the bathroom sink during the inspection, moving them into the locked garage.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan 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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2021 03:18 PM - It Cannot Be Edited


Created By: Amy Strother On 12/08/2021 at 02:07 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BAUSLEY, JACKIELYN FCCH

FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 files reviewed. Licensee and assistant, Adult 1 (A1) do not have current Mandated Reporter Trainings on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee stated that she and Adult 1 will complete their individual Mandated Reporter Trainings for Child Care Providers at www.mandatedreporterca.com by 12/22/21 and email certificates to LPA at amy.strother@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Licensee has three infants enrolled, Child 1-3 (C1-C3) and does not have a sleep log on file for C1-C3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2021
Plan of Correction
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Licensee stated that she will begin a safe sleep log for C1-C3 beginning 12/09/21 and submit documentation of sleep logs for C1-C3 to LPA on 12/13/21 via email to amy.strother@dss.ca.gov.
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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


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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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498
VISIT DATE: 12/08/2021
NARRATIVE
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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
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/08/2021 03:18 PM - It Cannot Be Edited


Created By: Amy Strother On 12/08/2021 at 02:22 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BAUSLEY, JACKIELYN FCCH

FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The trampoline accessible to children in the backyard has cracked plastic around the base of the trampoline and the fabric covering the springs was observed to be torn and worn away in many areas around the equipment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2021
Plan of Correction
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Licensee stated that she will remove the trampoline from the backyard and dispose of it. Licensee stated that she will take photos of her back yard as proof of the removal of the trampoline and submit photos to LPA via email at amy.strother@dss.ca.gov by 12/13/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan 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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


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