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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:18:26 PM

Document Has Been Signed on 04/11/2023 03:18 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: 16CENSUS: 9DATE:
04/11/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA), Amy Strother conducted a Plan of Correction (POC) visit and met with Licensee, Jackielyn Bausley (L1) for the purpose of following up on four Type B deficiencies that were cited on 03/08/23. L1 was cited for the following; an infant was observed asleep in an infant swing and was not moved to a crib or play yard, four out of four infants, C1-C4 all under 12 months, did not have form LIC9227 on file, L1 could not produce sleep logs for the four infants C1-C4 in care, and three out of four infants in care (C1, C2 and C4) did not have records for review, including but not limited to the LIC700 emergency information card. The purpose of today’s POC visit is to clear the above citations, all with a due date of 03/29/23.

During today's visit, LPA did not observe any of the infants in care to be sleeping. L1 had one infant swing in the room where care is provided, but the swing was not observed to be in use during today's visit. On 03/30/23 L1 submitted a procedure for how sleep routines would be conducted for infants, however it did not meet the requirements of the POC. L1 was given an opportunity to re-write the infant sleep routine procedure. During today's visit, LPA reviewed and approved L1's revised infant sleep routine procedure and obtained a copy. On 03/30/23 L1 submitted form LIC9227 for infants C1-C4. L1's infant sleep procedure included a plan for obtaining form LIC9227 and keeping a sleep log for infants. During today's visit, LPA observed and reviewed sleep logs for infants C1-C4, dated 03/06/23 - 04/11/23. LPA observed and reviewed complete records for C1, C2 and C4 as required.

All deficiencies issued on 03/08/23 have been cleared and Plans of Correction met.

Exit interview conducted and report reviewed with L1. 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. Appeal Rights were provided.

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.

LIC809 (FAS) - (06/04)
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