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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:52:13 AM

Document Has Been Signed on 08/11/2022 11:52 AM - 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: 10CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother arrived to the facility unannounced on 08/11/22 at 9:15am and met with Licensee Jackielyn Bausley (L1). Upon entering to the facility, LPA observed 6 children, Child 1 - Child 6 (C1-C6) being cared for in the front living room by 2 assistants, Staff 1 (S1) and Staff 2 (S2). Upon entering the home, LPA observed C1, an infant, sleeping in an infant swing. At 9:30am, at LPA’s request, S2 removed sleeping C1 from the infant swing, placing C1 into a pack n play that was set up in the family room. LPA observed S2 place C1 on their back, laying C1 on top of a blanket and pillow located inside of the pack n play. LPA advised S2 to remove the blanket and pillow from the pack n play. S2 removed the items.

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: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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
Document Has Been Signed on 08/11/2022 11:52 AM - It Cannot Be Edited


Created By: Amy Strother On 08/11/2022 at 11:34 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
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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Licensee (L1) stated she will read and review the infant safe sleep regulations with assistants S1 and S2. L1 will submit a copy of the infant safe sleep regulations with a statement that they have been read and understood, signed and dated by L1, S1 and S2.
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LPA observed infant C1, to be asleep in an infant swing located in the living room, which poses a potential Health and Safety risk to children in care.
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Type B
08/12/2022
Section Cited
CCR102425(b)

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(b) Cribs or play yards shall be free from all loose articles and objects.




This requirement was not met as evidenced by:
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Licensee (L1) stated she will read and review the infant safe sleep regulations with assistants S1 and S2. L1 will submit a copy of the infant safe sleep regulations with a statement that they have been read and understood, signed and dated by L1, S1 and S2.
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LPA observed infant C1, to be placed in a pack n play that contained a blanket and a pillow, which 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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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