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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 05/25/2022
Date Signed: 05/25/2022 04:59:39 PM

Document Has Been Signed on 05/25/2022 04:59 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 14CENSUS: 10DATE:
05/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother arrived to the facility unannounced on 05/25/22 at 1:50pm and met with Licensee Jackielyn Bausley (L1). Upon entering the facility, LPA observed 7 children, Child 1 - Child 7 (C1-C7) being cared for in the front living room by 2 assistants, Staff 1 (S1) and Staff 2 (S2). LPA observed C1, C2 and C3 to be swinging in individual infant swings and asleep. 3 out of 6 swings in the living room had blankets wrapped around the top pole of the swing, connected with a large clip. Each of the swings that C1-C3 occupied were either partially or completely covered by the clipped on blanket. LPA requested that the blankets be removed and asked where the children were going to sleep. Two children, C1 and C3 were moved onto a cot on the living room floor to sleep. C2 was moved into a pack and play that L1 went to the garage to obtain and S1 set up in the living room for C2. LPA observed 3 additional children, Child 8 - Child 10 (C8-C10) in the family room playing and watching television.

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.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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Document Has Been Signed on 08/11/2022 11:10 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/08/2022 01:15 PM


Created By: Amy Strother On 05/25/2022 at 04:27 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
102425(i)

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102425 Infant Safe Sleep (i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.
This requirement was not met as evidenced by:
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L1 will write an action plan to include having pack and plays set up prior to placing infants in swings, will no longer attach blankets onto swings and will move infants or other children from swings onto cots or pack and plays once asleep. L1 and 2 assistance will sign and date the action plan to be provided to LPA Strother.
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LPA observed 3 out 10 children (C1-C3) were observed to be asleep in infant swings located in the living room, C2 is an infant. This poses a potential Health and Safety risk to children in care.
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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: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
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