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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:28:08 AM

Document Has Been Signed on 09/04/2024 10:28 AM - 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: 2DATE:
09/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
10:42 AM
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Licensing Program Analyst (LPA), Amy Strother conducted a Plan of Correction (POC) visit and met with Licensee, Jackielyn Bausley (L1) for the purpose of following up on three Type B deficiencies that were cited on 08/14/24. L1 was cited for the following; licensee did not have records for review, including but not limited to the LIC700 emergency information card for children C1-C4 and C6, licensee did not have immunization records for children C1-C6 for review, and the licensee did not have a signed form LIC9224 required after receiving a Type A citation on 05/02/24 and 11/01/23 for children C1-C4 and C6 and child, C5 after receiving a Type A citation on 11/01/23. The purpose of today’s POC visit is to review the files of C1-C6 and clear the above citations, all with a due date of 08/21/24.

During today’s inspection LPA reviewed files for C1-C6. LPA review of records for C1-C6 determine that the licensee has all of the required documents on file at this time, clearing the deficiency and meeting the plans of correction.

All deficiencies issued on 08/14/24 have been cleared and Plans of Correction met.

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

Exit interview conducted and report reviewed with L1. 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.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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