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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 03/28/2025
Date Signed: 03/28/2025 04:20:26 PM

Document Has Been Signed on 03/28/2025 04:20 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: 28CENSUS: 11DATE:
03/28/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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A required inspection visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother. LPA arrived to the facility at 12:35pm, knocking on the door at 12:40pm. LPA was greeted at the door by assistant, Staff 1 (S1) who stated that Licensee, Jackielyn Bausely (L1) was not home but would be back soon. LPA entered the home and observed S1 providing care and supervision to a total of 11 children (3 infants and 8 preschool age children.) LPA asked S1 if there were any other assistants present. S1 stated that assistant S2 was not feeling well and was not working today. The facility was operating beyond the licensed capacity and ratio requirements. S1 called L1 who then spoke to LPA on the phone, stating that she left at 12:20pm and would be home shortly. At 12:51pm LPA observed that the child safety gate at the base of the stairs, located in the living room where all 11 children were present, was open making the staircase accessible to children. LPA pointed out the open gate to assistant S1, who then came over and closed the gate. LPA met with Licensee, Jackielyn Bausley (L1) at 12:53pm when she arrived to the facility.

LPA requested a current roster of children in care. L1 provided a three-page roster for LPA to review. LPA identified 10 of the 11 children present to be on the roster. L1 added child C2 to the roster when it was brought to her attention that their name was not listed. LPA then counted the number of children listed as enrolled on the roster to be 26. LPA asked L1 how many children were currently enrolled. L1 stated that 30 children were enrolled. LPA pointed out that there may be children not listed on the roster. L1 reviewed the roster stating that only two children were still missing from the roster and that she has 28 children enrolled and two starting next month. L1 then added two additional children to the roster who were not present during today’s visit.

LPA did not observe infants sleeping during today’s inspection. At 1:29pm LPA requested to review sleep logs for the infants present, C1, C9 and C11. L1 stated that all the infants present are over 12 months and can roll over.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Megan Aviles
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/28/2025
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L1 stated that she thought they didn’t need sleep logs once they were 12 months old and does not have sleep logs for them. LPA reminded L1 that infants are defined as 0-24 months and although form LIC9227, the Individual Infant Sleeping Plan, is only for infants up to 12 months, all other Infant Safe Sleep regulations, including sleep logs apply to infants up to 24 months.

LPA observed multiple examples of unsafe behavior between children. L1 and/or assistant S1 did not prevent children from engaging in unsafe behavior. At 1:14pm LPA observed child C7 put their arms around Child C6’s neck and squeeze tightly. C6 began to cry. L1 and S1 did not intervene. At 2:06pm S1 was helping two children get their shoes and jackets on for pick up at the front door in the living room. L1 was sitting on a chair in the living room with a child in her lap and on her cell phone. Child C7 went over to infant C11 who was standing up in a pack and play, and began to pull C11 from under the arms, attempting to lift C11, over and over. At 2:09pm C7 made a second visit to C11, this time pulling C11 by one arm multiple times. L1 and S1 made no verbal or physical attempt to intervene or redirect C7.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, 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.

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.

LPA Strother informed licensee Jackielyn Bausely that this report dated 03/28/25 documents 3 Type A citations. Type A citations shall be posted for 30 consecutive days as there is/are immediate risk(s) 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 03/28/25 that documents any Type A citation(s) 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.

NAME OF LICENSING PROGRAM MANAGER: Megan Aviles
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/28/2025 04:20 PM - It Cannot Be Edited


Created By: Amy Strother On 03/28/2025 at 03:29 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: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2025
Section Cited
CCR
102416.5(e)

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(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

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Licensee stated she will not leave the facility if there are more than 6 children present, unless she has two eligible assistants present. Licensee will send LPA Strother a written statement stating she will always be within ratio and how she wil meet the ratio requirement to LPA Strother. Email: amy.strother@dss.ca.gov
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Based on observation and interview, the licensee did not comply with the section cited above. Upon LPA's arrival the Licensee was not home and the assistant was supervising 11 children alone for approximately 33 minutes, which posed an immediate health, safety or personal rights risk to persons in care.
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Type A
03/29/2025
Section Cited
CCR102417(g)(3)

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(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

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LPA pointed out the open gate at the base of the stairs to assistant S1 who came over to the stairs, acknowledged the gate was open and closed the gate. Licensee will provide LPA with a written statement on how she will ensure the gate to the stairs remains closed at all times during day care hours.
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Based on observation, at 12:51pm, the gate at the base of the homes stair case was open, which posed an immediate health, safety or personal rights risk to persons 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.
Megan Aviles
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/28/2025 04:20 PM - It Cannot Be Edited


Created By: Amy Strother On 03/28/2025 at 03:33 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: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2025
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.

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Licensee stated she will submit a written plan on how to increase supervision and a plan to intervene and prevent unsafe behavior between children.
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LPA observed multiple occasions where children were engaging in unsafe behavior with other children and L1 and S1 did not step in to prevent the behavior, which poses an immediate health, safety or personal rights risk to persons 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.
Megan Aviles
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/28/2025 04:20 PM - It Cannot Be Edited


Created By: Amy Strother On 03/28/2025 at 03:34 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: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2025
Section Cited
CCR
102417(g)(8)

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(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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Licensee brought her roster current during today's visit. Licensee will submit a written statement outlining her procedure for ensuring that the roster remains current when new children are enrolled.
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Based on observation, interview, record review, the Licensee produced a roster, form LIC 9040 that was not complete. The roster was missing three children that are currently enrolled, including one that was present during today’s visit, C2, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/04/2025
Section Cited
CCR102425(j)(2)(D)

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The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.

This requirement is not met as evidenced by:
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Licensee stated she will review the Infant Safe Sleep regulations and begin completing Sleep Logs for the infants enrolled beginning 03/29/25. Licensee will send completed Sleep Logs for infants C1, C9 and C11 for the week of 03/29/25 - 04/04/25 to LPA Strother.
amy.strother@dss.ca.gov
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Based on record review and interview of Licensee, three infants were in care C1, C9 and C11 and Licensee was not completing sleep logs for any of the infants in care, including C1, C9 and C11, which poses a potential health, safety or personal rights risk to persons 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.
Megan Aviles
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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