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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:38:22 PM

Document Has Been Signed on 07/28/2023 03:38 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: 10CENSUS: 7DATE:
07/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
03:50 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 required inspection visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother. LPA met with Licensee, Jackielyn Bausley (L1). Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

During today’s visit, two assistants (S1 and S2) and L1 were supervising 8 children, 1 infant (C1), 6 preschool age children (C2-C7) and 1 school age child (C8) who is the child of L1. L1 was operating within the licensed capacity and ratio requirements. L1 provided a current roster of children in care as required. LPA verified that all children present during the visit were listed on the roster. LPA observed one infant (C1) sleeping during today’s visit. When LPA observed sleeping C1 at 2:48pm, C1 was observed to have a pacifier clip attached to the pacifier in her mouth. LPA asked S1 to remove the pacifier clip from C1’s pacifier. S1 removed the clip and patted C1's back to sooth her after the disturbance. LPA reviewed safe sleep logs for C1 and confirmed that form LIC9227 was in C1’s file. LPA made observations of staff interactions with children in care both outside and inside.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with licensee, Jackielyn Bausley.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 2
Document Has Been Signed on 07/28/2023 03:38 PM - It Cannot Be Edited


Created By: Amy Strother On 07/28/2023 at 03:02 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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2023
Section Cited
CCR
102425(b)(1)(A)

1
2
3
4
5
6
7
102425 Infant Safe Sleep(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A)There shall not be anything attached to the pacifier.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated that she will post the "What does a safe sleep environment look like?" handout in the room where infants sleep as a visual aid and reminder that the play yard should only have a fitted sheet present in play yard.
8
9
10
11
12
13
14
Based on LPA observation, at 2:48pm C1 was asleep on their back in the play yard. LPA observed that C1 had a pacifier in her mouth, the pacifier had a ribbon attached to it and a clip attached to C1's shirt, which poses a potential health and safety risk to the child in care.
8
9
10
11
12
13
14
Licensee stated she will create a visual aide demonstrating pacifiers okay, but no pacifier clips and post it in the sleep environment. L1 will send photo of visual aides posted to LPA Strother at 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.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2