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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:27:06 PM

Document Has Been Signed on 03/21/2024 04:27 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
SANTA ROSA CC RO, 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: 17CENSUS: 12DATE:
03/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
04:30 PM
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A required inspection visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother.

During today’s visit, two assistants (S1 and S2) were supervising 12 children, 3 infants and 9 preschool age children, operating within the licensed capacity and ratio requirements. S1 stated that Licensee Jackielyn Bausley (L1) was out, but would be home soon. L1 arrived to the home at approximately 12:35pm and provided a current roster of children in care as required. LPA verified that all children present were listed on the roster. LPA reviewed safe sleep logs for the 3 infants in care (C6, C8 and C11). LPA made observations of staff interactions with children in care observing S1 and S2 redirecting children to play with another toy or to play in a different area when conflict between children occurred.

There were no Title 22 deficiencies cited during today's inspection.

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: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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