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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 04:08:27 PM

Document Has Been Signed on 05/15/2024 04:08 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
04:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother arrived to the facility unannounced for the purpose of conducting a Plan of Correction visit and to review children's files. When LPA arrived, 2 assistants (S1 and S2) were supervising 10 children, 2 infants (C2 and C3) and 8 preschool age children C1 & C4-C10. S1 stated that the Licensee would arrive shortly. Licensee Jackielyn Bausley (L1) arrived at 2:20pm. LPA toured the facility. LPA observed 2 children, C1 and C7 sleeping together side by side in a play yard. When L1 arrived, she identified C1 and C7, stating that they are 4 years old and 3 years old. Manufacturer warnings of a similar product state to stop using the product when a child reaches 35 inches in height, weighs more than 30 lbs or is able to climb out.

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 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 04:08 PM - It Cannot Be Edited


Created By: Amy Strother On 05/15/2024 at 03:30 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
CCR
102423(a)(2)

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102423 Personal Rights (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement has not been met as evidenced by:
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Licensee stated that she will use a toddler size mattress covered with a fitted sheet on the floor for children C1 and C7 to sleep on side by side together from now on. Licensee showed LPA the toddler mattress and fitted sheet that will be used during the visit.
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Based on observations made by LPA on 05/15/24 at 2:07pm, the licensee placed two children, C1 and C7 in the same play yard to take a nap. Manufacturer warnings of a similar product state to stop using the product when a child reaches 35 inches in height, weighs more than 30 lbs or is able to climb out. C1 and C7 observed by LPA sleeping side by side in the same play yard weigh over 30 lbs combined, this poses a potential personal rights 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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