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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:56:17 PM

Document Has Been Signed on 08/14/2024 12:56 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: 19CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jackielyn Bausley TIME VISIT/
INSPECTION COMPLETED:
01:10 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 or working in the home, 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 a total of 6 children; 1 infant (C1), 4 preschool age children (C2-C5) and 1 school-age child (C6), 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 were listed on the roster. LPA observed one child sleeping in a play yard (C2), C2 is over two years of age. LPA reviewed safe sleep logs for C1 and observed form LIC9227 to be on file for C1, as required. LPA requested to review the files of the six children present (C1-C6). Upon record review C1 only had form LIC9227 and a sleep log on file, but no other records as required. C1-C4 & C6 did not have Acknowledgement of Receipt of Licensing Report (LIC 9224) on file for Type A citations issued within the last 12 months (05/02/24 & 11/01/23). C5 did have LIC9224 on file for the 05/02/24 Type A citation, but did not have form LIC9224 for the 11/01/23 Type A citation. C1-C6 not have proof of immunization's on file as required. C1-C4 and C6 did not contain forms/records on file as required, including LIC700, LIC627, LIC995A and LIC282. LPA made observations of staff S1 & S2 interacting with children in care. S1 & S2 used gentle tones of voice when interacting with the children. S2 was heard humming along to the song playing on the television and engaging in interaction with C1, as well as feeding C1 a bottle. S2 sat in the room supervising the children and then prepared lunch.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, and Health and Safety Code were observed: see LIC 809D. Appeal Rights were provided. A civil penalty in the amount of $250 is assessed on form LIC421FC for a repeat violation.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/14/2024
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
26
27
28
29
30
31
32
PAGE 2

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: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 08/14/2024 12:56 PM - It Cannot Be Edited


Created By: Amy Strother On 08/14/2024 at 11:54 AM
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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
CCR
102417(g)(7)

1
2
3
4
5
6
7
 An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee will obtain forms LIC700, LIC627, LIC995A, LIC282 for C1-C4 and C6 from the parents/guardians of C1-C4 and C6 and have the completed files by the POC due date.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above in 5 out of 6 children's files requested. Licensee does not have LIC700's on file for Child 1 – Child 4 and Child 6 (C1-C4 and C6) which poses a potential health, safety or personal rights risk to persons in care.
Files for C1-C4 and C6 are missing the following additional forms, LIC627, LIC995A, LIC282.
8
9
10
11
12
13
14
Type B
08/21/2024
Section Cited
CCR102418(a)

1
2
3
4
5
6
7
Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee stated she would obtain record of C1-C6’s immunizations and transcribe onto form CDPH286, placing documentation of immunization records and CDPH286 by the POC due date.
8
9
10
11
12
13
14
Based on record review, the were no record of immunizations for children C1-C6 on file, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/14/2024 12:56 PM - It Cannot Be Edited


Created By: Amy Strother On 08/14/2024 at 11:54 AM
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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
HSC
1596.8595(c)(1)

1
2
3
4
5
6
7
(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:
1
2
3
4
5
6
7
Licensee stated she would provide copies of the reports dated 05/02/24 and 11/01/23 to guardians of children C1-C4 & C6 and of report dated 11/01/23 to guardian of C5 and obtain signed form LIC9224 from guardians of C1-C6, placing the documentation in files for C1-C6 by POC due date.
8
9
10
11
12
13
14
Based on interview with Licensee Child 1 - Child 4 and Child 6 (C1-C4 and C6) files did not contain a signed form LIC9224 required after receiving a Type A citation on 05/02/24 and 11/01/23. Child 5 (C5) did not contain a signed form LIC9224 required after receiving a Type A citation on 11/01/23.which poses a potenial health and safety risk to the children in care.
8
9
10
11
12
13
14

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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4