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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009498
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:41:16 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20220712165500
FACILITY NAME:BAUSLEY, JACKIELYN FCCHFACILITY NUMBER:
493009498
ADMINISTRATOR:BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:14CENSUS: 8DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Licensee did not notify child’s authorized representative of child’s injury

Day care child was restrained while in care
INVESTIGATION FINDINGS:
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A subsequent complaint investigation inspection was conducted at the facility by Licensing Program Analyst (LPA), Amy Strother to deliver complaint investigation findings. LPA met with Licensee Jackielyn Bausley. It has been alleged that Licensee did not notify child’s authorized representative of child’s injury, specifically that the Licensee did not notify a child’s authorized representative that a child’s face was red and swollen and appeared to have an allergic reaction on one occasion and fever on another occasion. It has also been alleged that a day care child was restrained while in care, specifically that the child was placed in an infant rocker to watch TV.

During the initial investigation visit on 07/20/22, LPA requested and received a current roster of children in care, interviewed the Licensee (L1) and two children, Child 2 and Child 3 (C2 -C3). L1 denied the allegations stating that no children have become ill or injured while in care and that no parent has told her that they took their child to the doctor due to an injury.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 01-CC-20220712165500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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 L1 also denied that any child is placed in the swing to watch TV, stating that the swings are only used for helping the children to fall asleep and then they are moved to a bed. Interviews with children C2 and C3 indicated that the swings are used for the babies to sleep.
LPA conducted interviews with 5 adults, Adult 1 – Adult 4 and Adult 6 (A1-A4 and A6) between 07/19/22 and 09/16/22. Interviews conducted with L1’s assistants on 09/16/22 stated that they could not think of a time that a child in care had a rash/allergic reaction or a fever while in care, and that swings are only used to help children fall asleep, corroborating what L1 stated. LPA received screen shots of text communication with L1 and photos of a child that had pink coloring on the cheeks, nose and eyebrows on 07/19/22 and 07/20/22 after an interview was conducted with Adult 1 and Adult 2. Adult 2 stated during an interview that they didn't notice a rash when they picked their child up, but when home noticed what looked like welts or hives all over their body. Further stating that the pink coloring seen on the child’s face would come and go, stating that the doctor was unable to give a diagnosis. A review of text messages between adult and L1 indicates that the adult was informing L1 of the child’s illness, but does not indicate that L1 was aware of the illness prior to receiving the text. A6 stated in an interview that their children have never been ill or injured in care and that she has regular communication with L1.

Although interviews and record review corroborate that a child in care did have an allergic reaction to something and was diagnosed with a fever due to an ear infection, based on information gathered during interviews, there is not a preponderance of evidence to support that the Licensee or assistants were aware that the child had an allergic reaction or a fever while in care. Based on interviews conducted there is not a preponderance of evidence to support that the swing is used for any purpose other than to help children fall asleep.
Based on interviews conducted and records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that an alleged violation occurred, therefore the allegations are UNSUBSTANTIATED.
There were no Title 22 deficiencies cited based on the above allegations during today's inspection. This report was reviewed and discussed with the Licensee. Appeal Rights were provided.
Notice of Site Visit shall be posted for 30 days from today's visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Amy Strother
COMPLAINT CONTROL NUMBER: 01-CC-20220712165500

FACILITY NAME:BAUSLEY, JACKIELYN FCCHFACILITY NUMBER:
493009498
ADMINISTRATOR:BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:2775 CUMBERLAND STREETTELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:14CENSUS: DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Licensee is using unsafe equipment for child in care
INVESTIGATION FINDINGS:
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A subsequent complaint investigation inspection was conducted at the facility by Licensing Program Analyst (LPA), Amy Strother to deliver complaint investigation findings. LPA met with Licensee Jackielyn Bausley. It has been alleged that Licensee is using unsafe equipment for child in care, specifically that an infant swing is being used for a child who is 25 lbs or more.

During the initial investigation visit on 07/20/22, LPA requested and received a current roster of children in care, interviewed the Licensee (L1) and two children, Child 2 and Child 3 (C2 -C3). During the visit on 07/20/22 LPA observed 3 out of 4 infant swings occupied by children, Child 4 (C4) age 15 months (legs reached beyond the edge of the seat), Child 5 (C5) age 15 months (legs reached beyond the edge of the seat), and Child 6 (C6) age 23 months (legs were observed to be bent and tucked upward while L1 pushed the swing by hand). LPA noted that C4 and C5 were partially strapped into the swing, using one over the shoulder harness, while C6 did not appear to be strapped into the swing.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 01-CC-20220712165500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/29/2022
NARRATIVE
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LPA conducted interviews with 5 adults, Adult 1 – Adult 4 and Adult 6 (A1-A4 and A6) between 07/19/22 and 09/16/22. LPA reviewed the swing manufacturer warning label and product information sheet through an internet search. Swing warning sticker states the following: “WARNING: Prevent death..., Prevent serious injury or death from falls or strangling in the restraint system" -Never leave child unattended. -Always use the restraint system. - This product is not intended to replace a crib or bassinet for prolonged periods of sleep. - Discontinue use when an active child attempts to climb out.” Product information sheet states that the maximum weight limit is 25 lbs, but if child is active and appears to be able to climb out of the swing, immediately discontinue its use. Adult interviewed stated that their child has been observed in the swing and weighs 25 lbs or more and that they have told the Licensee that their child has fallen out of an infant swing at home and shared a concern with the licensee that if they use the swing that they may fall out. On 07/20/22 at 1:13pm LPA observed C6 climb into the swing unassisted and then back out of the swing.

Based Interviews conducted, a review of swing manufacturer warnings and LPA observations, the preponderance of evidence standard had been met. It has been corroborated that the swings present at the facility have been used on more than one occasion, including during LPA’s visit on 07/20/22 by children C1 – C4 that are either beyond the swing manufacturers maximum weight limit of 25lbs, able to climb in and out of the swing or not fully restrained with the harness as directed by the manufacturer, therefore making the equipment unsafe.
Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099-D.

Appeal Rights were provided and exit interview conducted. The Notice of Site Visit must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 01-CC-20220712165500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
102423(a)(2)
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102423 Personal Rights (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
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L1 stated that swings will be used with non-mobile infants under 25 lbs. w/restraint system used each time an infant is placed in swing. L1 understand if an infant falls asleep in the swing they will be moved as soon as possible to a crib. L1 signed a statement to the above, stating she will train assistants.
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This requirement is not met as evidenced by: based on observations and interviews, the licensee did not follow the swing manufacturers warnings or product information guide and placed multiple children in care (C1-C4), on more than one occasion in the swings that were either beyond the maximum weight of 25 lbs, active and able to climb out and/or did not use the restraint system. This poses a potential personal rights risk or health and safety risk to the 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.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5