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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009498
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:49:18 AM

Unsubstantiated


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
09/10/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240910102020
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: 7DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee is submitting fraudulent documents to subsidy program
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Strother made a subsequent complaint investigation inspection, for the purpose of delivering complaint findings, and met with the Licensee, Jackielyn Bausley (L1). It has been alleged that the Licensee submitted fraudulent documents to a subsidy program, specifically that L1 submitted forged child care expense claims for reimbursement for dates that child (C1) was no longer attending care with a L1’s child care facility.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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-20240910102020
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: 11/25/2024
NARRATIVE
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During the initial investigation inspection on 09/17/24, LPA Strother conducted an interview with L1 regarding the allegation. A Child Care Facility Roster of children was obtained. L1 denied the allegation stating that C1’s authorized representative signed the documents that she submitted for reimbursement and that when C1 was absent from care, L1 wrote “absent” on the form, stating that it is the subsidy programs decision to pay or not pay.

LPA conducted interviews with four adults, (A1-A4) between 09/11/24 and 11/25/24. LPA requested and obtained records between 09/11/24 and 11/21/24. Based on interview and record review it could not be determined if the claim forms submitted by L1 were forged. It was determined through interview with A4 and a review of records received, that the subsidy program reimbursed L1 following written guidelines found in All County Letter (ACL) No. 19-99.

Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that an alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

This report was reviewed and discussed with Licensee, Jackielyn Bausley. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
09/10/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240910102020

FACILITY NAME:BAUSLEY, JACKIELYN FCCHFACILITY NUMBER:
493009498
ADMINISTRATOR:BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:2775 CUMBERLAND STREETTELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:14CENSUS: 7DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee does not provide a safe environment for children in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Strother made a subsequent complaint investigation inspection, for the purpose of delivering complaint findings, and met with the Licensee, Jackielyn Bausley (L1). It has been alleged that the Licensee does not provide a safe environment for children in care, specifically that L1 and/or assistants did not prevent child (C1) from engaging in unsafe behavior when C1 was standing on a table and jumping onto furniture.

During the initial investigation inspection on 09/17/24, LPA Strother conducted interviews with L1 and two assistants (S1 & S2). A Child Care Facility Roster of children was obtained. L1 denied the allegation stating that she could not think of a time that children were standing on a table or jumping on furniture. S1 denied that any child walked on top of the green table and stated that if children jump on the couch they are told to get down. S2 stated that children are not allowed to go on the table and are not allowed to jump from the table to the couch, stating they have never needed to prevent this from happening because they have never witnessed it.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 01-CC-20240910102020
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: 11/25/2024
NARRATIVE
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LPA conducted an interview with Adult 1 (A1) on 09/11/24 and received video footage dated 06/08/22, on 09/16/24. LPA Strother viewed the video and observed the following: A child, identified as C1, is seen walking back and forth on a child's size green rectangle shaped table. There are four green chairs stacked on one another next to the table. The tables long edge appears to be either very close to or touching the edge of the brown sectional couch. There is a second child, female, name unknown, sitting on the couch. For 27 seconds child (C1) walks from one end of the table to the other, then exclaims, "watch out" to the child on the couch and jumps onto the couch from the table. The video pans back and forth from right to left, left to right, suggesting that it is being held by an individual who is recording the incident. There is no information on who is holding the camera. There is a large television on the right side of the couch, which is on. The television can be heard at a high volume on the video recording. A baby is heard crying but is not visible in the recording. There is a play yard visible in the recording, however it is not clear if a child is inside of it. At the end of the 30 second video, although difficult to hear, it sounds like the voice of an adult speaking.

Based on the evidence obtained through interview and review of the video dated 06/08/22, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC9099-D. Appeal rights were provided.

LPA Strother informed Licensee, Jackielyn Bausley that this report dated 11/25/24 documents one Type A citation. Type A citations 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 Strother informed the Licensee to provide a copy of this licensing report dated 11/25/24 that documents a Type A citation 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.

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

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: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 01-CC-20240910102020
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: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
102423(a)(2)
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(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 is not met as evidenced by:
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Licensee will submit a written statement on how she will ensure supervision, redirection of children's undesired behavior to provide a safe environment by 11/26/24. Send via email to amy.strother.dss.ca.gov.
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Based on interview and record reviewed, on 06/08/22 C1 was recorded on video walking back and forth on top of a child size table for 27 seconds without an adult redirecting C1’s behavior, and then jumped onto a couch where another child was sitting. This poses an immediate health and safety and 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.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5