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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 07/17/2025
Date Signed: 07/17/2025 12:23:57 PM

Document Has Been Signed on 07/17/2025 12:23 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: 29CENSUS: 8DATE:
07/17/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
12:38 PM
NARRATIVE
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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, LPA observed the Licensee and two assistants (S1 and S2) supervising the children in the living room. LPA asked L1 how many children were in care today. L1 stated 7 children (two infants (C1 & C2: both over 12 months old) and 5 preschool age children (C3-C7). LPA counted the children and only observed 6 children in the room. At 9:22am L1 pointed out that the seventh child was sleeping, pointing to the train table in the room. LPA observed child (C3) sleeping on the train table on top of a blanket and covered with a blanket. One additional child, C8 (preschool age) arrived within the first 10 minutes of the visit. At LPA's request, L1 removed C3 from the train table, moving C3 to the couch.

LPA toured the bathroom, opening the accessible drawers and cupboards under the counter. At 9:39am LPA observed over the counter medication, "advanced scar gel" accessible in the right side draw. The medication had warnings regarding calling poison control if ingested, confirming that the item is hazardous to children. LPA requested that L1 remove the item from the drawer, L1 complied moving the medication to an area that was inaccessible to children.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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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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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Document Has Been Signed on 07/17/2025 12:23 PM - It Cannot Be Edited


Created By: Amy Strother On 07/17/2025 at 11:28 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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
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.

This requirement is not met as evidenced by:
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L1 stated she will use the cots or crib mattresses on the floor for children over the age of two. L1 will submit a written statement of where children will be placed to sleep and how equipment will be used for it's intended purpose.
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Based on observation at 9:22am, child C3 was observed asleep on top of a train table, which posed 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 12:23 PM - It Cannot Be Edited


Created By: Amy Strother On 07/17/2025 at 11:35 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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
102417(g)(4)

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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 be limited to: (4)Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
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Licensee removed the medicatioin from the bathroom during today's visit. Licensee stated she will submit a plan for preventing the storage of hazardous items in areas that are accessible to children.
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Based on observation at 9:39am there was over the counter medication, "advanced scar gel" accessible in the right side bathroom drawer. The medication had warnings regarding calling poison control if ingested, confirming that the item is hazardous to children, which poses an immediate health and safety and personal rights risk to the children in care.
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Type A
07/18/2025
Section Cited
CCR102423(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 made the backyard off-limits during today's inspection and updated form LIC999A yard sketch listing the backyard as off limits, submitting to LPA Strohter. Licensee will submit a statement on how the backyard will remain inaccessible to children.
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Based on observation at 9:44am, the backyard had multiple hazards, including: unstable deck steps, loose fence boards, leaning privacy fencing coming loose from the main fence boards, adult size garden tools stored in the children's play house, broken plastic ride on toys with sharp edges, a broken wooden chair; missing a leg and the seat, a roll of wire fencing with sharp ends which 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 12:23 PM - It Cannot Be Edited


Created By: Amy Strother On 07/17/2025 at 11:46 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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
102425(i)

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If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
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Licensee stated that she will submit a statement of her understanding that infants must be placed in a crib or play yard when observed to be asleep and the responsibility to educate her assistance of all infant safe sleep regulations.
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Based on observation at 10:51am, LPA observed infant C1 sleeping on a sofa chair, which 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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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: 07/17/2025
NARRATIVE
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At 9:44am LPA toured the back yard, listed as an on-limits area of the home. LPA asked L1 if the backyard is used for care. L1 stated it is used, but they like to take the children to the neighborhood park. LPA opened the slider door to be unlocked and toured the backyard. LPA observed multiple hazards, including: unstable deck steps, loose fence boards, leaning privacy fencing coming loose from the main fence boards, adult size garden tools stored in the children's play house, broken plastic ride on toy with sharp edges, a broken wooden chair; missing a leg and the seat, a roll of wire fencing with sharp edges. LPA Strother informed L1 that she would need to immediately make the backyard off-limits. L1 locked the door latch and the extra lock on the upper right side of the door, making the backyard inaccessible to children.

L1 provided a current roster of children in care as required. LPA verified that all children present were listed on the roster. LPA reviewed safe sleep logs for C1 and C2, sleep logs were current. At 10:51am, LPA went back to the living room to observe any infants that may be sleeping. Infant, C1 was observed sleeping on a sofa chair. No adult was sitting next to or on the chair. Infant C2 was observed sleeping in a play yard. LPA requested that C1 be moved to a play yard. C1 was moved to the available play yard in the living room.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

LPA Strother informed licensee Jackielyn Bausley that this report dated 07/17/25 document(s) three Type A citation(s) which 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 07/17/25 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: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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