<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 03/08/2023
Date Signed: 03/08/2023 01:53:02 PM

Document Has Been Signed on 03/08/2023 01:53 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: 13CENSUS: 9DATE:
03/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Case Management inspection was conducted by Licensing Program Analyst (LPA) Amy Strother due to a report received from Community Care Licensing Division Investigations Branch on 03/01/23. LPA met with Licensee Jackielyn Bausley (L1). The Investigations Branch report noted that on 02/21/23 investigator, S. Guerra made a visit to L1’s Family Child Care Home. Guerra’s report stated that during the visit, S. Guerra directly observed three infants laying in swings, observing that least one of the three infants was sleeping.

During today’s inspection, the facility was toured, LPA observed 9 children in care, 4 of the 9 children were infants, all under the age of one year. Infants were not observed to be sleeping when LPA arrived. LPA observed one infant (C4) was asleep, laying on their back in a play yard during the inspection. LPA requested files for the four infants in care (C1-C4). At 12:20pm L1 stated that she does not have files for C1, C2 or C4 and only has a file for C3. LPA reviewed C3's file and did not find a LIC9227 Individual Sleeping Plan on file as required. LPA requested to review documentation (sleep logs) of 15 minute sleep checks including the date, infant's name and time of each 15 minute check for C1-C4. L1 provided sleep logs for C1-C4 with dates 03/06/23 - 03/08/23. LPA asked to review sleep logs for dates prior to this week. L1 stated that she threw them out. LPA reminded L1 of the requirement to keep all records for 3 years.

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.

There is a repeat violation within the last 12 months. On 05/25/22 L1 was cited based on LPA Strother observing three children asleep in a swing, one of three children was an infant. Again, on 08/11/22 L1 was cited based on LPA Strother observing one infant asleep in an infant swing located in the living room during an unannounced visit to the facility. LPA assessed and issued a Civil Penalty of $250 for a repeat citation within a 12 month period.

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: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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 3
Document Has Been Signed on 03/08/2023 01:53 PM - It Cannot Be Edited


Created By: Amy Strother On 03/08/2023 at 08:36 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: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited
CCR
102425(i)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
L1 stated that she will ensure that infants will be placed in a play yard once asleep. L1 stated that she is choosing to remove all of the infant swings from the facility and discontinue using them. L1 will write a procedure for how sleep routines will be conducted for infants in care that L1 and assistants will follow.
8
9
10
11
12
13
14
Based on record review, one out of three infants observed in infant swings on 02/21/23 were asleep in a swing, which poses a potential Health and Safety risk to infants in care.
8
9
10
11
12
13
14
Written procedure will be provided to LPA by 03/29/23 amy.strother@dss.ca.gov
Type B
03/29/2023
Section Cited
CCR102425(c)

1
2
3
4
5
6
7
102425(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated that she will ensure that a parent or guardian of C1-C4 and of any infants under 12 months enrolled in the future will complete the LIC 9227 to be kept in the infant's file. L1 will write a procedure for enrolling infants to include forms needed and when the forms will be obtained.
8
9
10
11
12
13
14
Based on interview, Licensee stated that she does not have form LIC9227 for any of the infants (C1-C4) in care. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
L1 will submit copies of LIC9227 for C1-C4 to LPA along with L1's procedure for enrolling infants into care. 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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/08/2023 01:53 PM - It Cannot Be Edited


Created By: Amy Strother On 03/08/2023 at 12:53 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited
CCR
102425(j)(2)(D)

1
2
3
4
5
6
7
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated she will continue to conduct sleep checks, visually checking on C1-C4 every 15 minutes, logging C1-C4's names, date and time of each check and keep logs on file for three years for any infants in care, including C1-C4.
8
9
10
11
12
13
14
Based on interview and record review, Licensee stated that she only has sleep logs for C1-C4 for the week of 03/06/23 and does not have record of past sleep logs available for review. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/29/2023
Section Cited
CCR102417(g)(7)

1
2
3
4
5
6
7
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain forms LIC700, LIC627, LIC995A, LIC282, LIC9224 (providing report dated 08/11/22) and copies of immunization records to transcribe onto CDPH286 for C1, C2 and C4 from the parents/guardians of C1, C2 & C4 and have the completed files by 03/29/23.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above in 3 out of 4 children's files requested. Licensee does not have LIC700's on file for C1, C2 & C4 which poses a potential health, safety or personal rights risk to persons in care.
Files for C1, C2 and C4 are missing the following additional forms, LIC627, LIC995A, LIC282, Immunization records and LIC9224 for Type A citations issued on 08/11/22.
8
9
10
11
12
13
14
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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3