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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009498
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:32:05 PM

Substantiated


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
11/22/2022 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20221122113731
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: 9DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Adult in home handled day care child in a rough manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 an adult in the home (A1) handled day child (C1) in a rough manner, specifically that adult (A1) grabbed child (C1) by the arm in an aggressive way at the time of drop off.
During the initial investigation on 03/08/23, LPA Strother toured the facility, obtained a current roster and conducted interviews with the Licensee (L1), two assistants, A1 and A2 and one child (C2). Although A1 denied grabbing children during an interview on 03/08/23, A1 did state that he will tightly hug a child so they don’t run into the metal screen door when they cry and try and chase their mom or dad, corroborating the allegation that A1 handled a day care child in a rough manner. Based on interview, the preponderance of evidence standard had 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.
Continue LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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 4
Control Number 01-CC-20221122113731
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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2023
Section Cited
CCR
102423(a)(1)
1
2
3
4
5
6
7
Personal Rights (a)Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged.... These rights include, but are not limited to, the following: (1)To be treated with dignity in his/her personal relationship with staff and other persons.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will complete a training called "The Pyramid Model Goes to Family Child Care Homes" that looks at how to work with challenging behavior and Promoting Social Emotional Competence in Infants and Young Children: https://challengingbehavior.org/webinar/the-pyramid-model-goes-to-family-child-care-homes/.
8
9
10
11
12
13
14
Based on interview, A1 stated that he will tightly hug a child so they don’t run into the metal screen door when they cry for their parent, which poses a potential Health and Safety or Personal Rights risk to children in care.
8
9
10
11
12
13
14
Additionally L1 will write a statement on how to handle difficult situations with children without having physical contact with them. L1 stated that she understands that she needs to train her staff on how to meet the personal rights regulations. L1 will submit written statement to LPA Strother by 04/18/23 emailing it to amy.strother@dss.ca.gov
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 01-CC-20221122113731
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: 04/11/2023
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
26
27
28
29
30
31
32
Exit interview conducted and report was reviewed with License, Jackielyn Bausley. A notice of site visit was given and must remain 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: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
11/22/2022 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20221122113731

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: 9DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Adult in home inappropriately restrained day care child.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 an adult in home (A1) inappropriately restrained day care child, specifically that child (C1) was restrained in a highchair while in care.
During the initial investigation on 03/08/23, LPA Strother toured the facility, obtained a current roster and conducted interviews with the Licensee (L1), two assistants, A1 and A2 and one child (C2). During the course of the investigation there was no corroborating evidence to prove that children have been inappropriately restrained in highchairs since the facility was cited on 08/11/22 for the same allegation, see complaint control number 01-CC-20220516132419.
Based on record review and interviews conducted, there is not a preponderance of evidence to support the allegation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that an alleged violation occurred beyond the 08/11/22 date, therefore the allegation is UNSUBSTANTIATED.
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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4