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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:45:51 PM

Document Has Been Signed on 05/15/2024 03:45 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/
DIRECTOR:		BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 10DATE:
05/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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An unannounced Plan of Correction (POC) visit was conducted by Licensing Program Analyst (LPA) Amy Strother. The purpose of the visit was to follow up on the Plan of Correction for a Type A citation and unsure that the facility was maintaining compliance. LPA met with Licensee, Jackielyn Bausley (L1).

On 05/02/24, LPA delivered compliant investigation findings to L1. On 05/02/24, the facility was cited a Type A deficiency due to the Licensee not ensuring that a sleeping infant in care (C1) was moved from a swing to a play yard as soon as possible. Based on interview and record review, C1 was observed sleeping in a swing on 12/07/23 for at least 32 minutes. L1’s plan of correction for the citation was a written statement provided to LPA Strother, stating that L1 will no longer use infant swings, will remove them from her facility and that she understands that infants must be placed in a crib or play yard as soon as possible when sleeping.

During today’s POC visit, 2 assistants (S1 and S2) were supervising 10 children, 2 infants (C2 and C3) and 8 preschool age children C1 & C4-C10) when LPA arrived. S1 stated that the Licensee would arrive shortly. L1 arrived at 2:20pm. LPA toured the facility. Infants C2 and C3 were not observed sleeping during today's inspection. LPA observed that the infant swings had been removed from the room. LPA did not observe infant swings in any room during the visit. The plan of correction has been met, and the deficiency cleared.

LPA attempted to verify that the Parents/guardians had signed a form LIC9224 for each child's file for the 05/02/24 Type A citation. At 2:29pm L1 stated that she did not yet provide a copy of the report dated 05/02/24 to the parents of children currently enrolled and did not have form LIC9224 on file for the children present during today's visit, C1-C10.

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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Jackielyn Bausley.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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Document Has Been Signed on 05/15/2024 03:45 PM - It Cannot Be Edited


Created By: Amy Strother On 05/15/2024 at 03:21 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
HSC
1596.8595(c)(1)

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(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.

This requirement has not been met as evidenced by:
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Licensee stated that she will ensure that parents of C1 – C10 will sign and date the LIC9224 forms after receiving a copy of the 05/02/24 report and will scan and email signed copies of the LIC9224 forms to LPA Strother by 05/17/24 at amy.strother@dss.ca.gov

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Based on interview with Licensee Child 1 - Child 10 (C1-C10) files did not contain a signed form LIC9224 required after receiving a Type A citation on 05/02/24, which poses a potenial health and safety risk to the children 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.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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