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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009498
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:30:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 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
03/18/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240318095159
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: 10DATE:
05/02/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jackielyn BausleyTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Licensee did not provide appropriate sleeping arrangements for day care children.
INVESTIGATION FINDINGS:
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A follow-up compliant investigation visit was made by Licensing Program Analyst (LPA), Amy Strother to deliver complaint investigation findings. It has been alleged that the Licensee did not provide appropriate sleeping arrangements for a day care child, specifically that on 12/07/23 an infant was observed sleeping in an infant swing.

During the initial investigation inspection on 03/21/24, LPA Strother conducted interviews with one child (C1), who qualified to be interviewed, the Licensee (L1) and two assistants (S1 & S2). A Child Care Facility Roster of children was obtained. L1 stated that her assistants, S1 and S2 were on vacation from 11/30/23 – 01/12/24, further stating that the children sleep on cots or in pack and plays.

During the investigation, LPA Strother received records and interviewed one adult, A1 on 03/18/24 and a second adult, A2 on 03/28/24.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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 5
Control Number 01-CC-20240318095159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FCCH
FACILITY NUMBER: 493009498
VISIT DATE: 05/02/2024
NARRATIVE
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When interviewed by LPA, A1 reported that on 12/07/23 they observed 10 children (C1-C10) in care with L1, three of whom were infants under the age of 2 years old (C1-C2 & C5). A1 stated they observed a child asleep in a swing, who appeared to be not much older than 1 year old. A1 stated that they did not know the name of the child, but that they have been around enough children to know that the child in the swing was under 2 years old. A2 corroborated A1's statements, reporting that on 12/07/23 they observed a child, who they believe was C1, sleeping in a swing for approximately 35 minutes. LPA’s review of records included a list of 10 children (C1-C10) whom were in care with L1 on 12/07/23, between 2:48pm and 3:20pm. LPA cross checked the names of the children reported to have been in care on 12/07/23 between 2:48pm and 3:20pm with the names and birth dates listed on the Child Care Facility Roster obtained on 03/21/24. A review of C1-C10's ages, indicates that C1 and C2 were infants, under the age of 2 years on 12/07/23, and C3 – C10 were all over the age of 2 years on 12/07/23.

Based on interviews with A1 and A2 and record review, there is a preponderance of evidence to indicate that C1, an infant, was sleeping in a swing for at least 32 minutes on 12/07/23 therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided.

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

LPA Amy Strother informed licensee, Jackielyn Bausley that this report dated 05/02/24 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Amy Strother informed the licensee to provide a copy of this licensing report dated 05/02/24 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report.

A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 01-CC-20240318095159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FCCH
FACILITY NUMBER: 493009498
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
102425(i)
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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:
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L1 provided LPA with a written statement, stating that she will no longer use the infant swings, removing them from her facility. L1 wrote in the statement that she understands that infants must be placed in a crib or play yard as soon as possible when sleeping.
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Based on interview and record review, an infant (C1) was observed sleeping in a swing on 12/07/23 for at least 32 minutes, which posed an immediate Health and Safety risk to the infant in care.
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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: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
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