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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 03/12/2026
Date Signed: 03/12/2026 12:10:21 PM

Document Has Been Signed on 03/12/2026 12:10 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: 22CENSUS: 4DATE:
03/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother made an unannounced visit to the facility for the purpose of conducting a complaint investigation visit. This Case Management visit is added to today’s visit as a result of information obtained during the complaint investigation. LPA met with Licensee, Jackielyn Bausley (L1). During the complaint investigation, LPA conducted interviews as follows:

During the initial investigation visit on 12/29/25 LPA conducted interviews with one child (C1) and the Licensee (L1). L1 denied that child care children have been upstairs, stating, I have never had day care children upstairs.

LPA conducted interviews between 02/04/26 and 03/09/26 with 10 adults, Adult 1 – Adult 8 (A1-A8), Staff 1 & Staff 2 (S1 & S2) who are assistants at the Family Child Care Home facility, and 2 additional children, Child 2 & Child 3 (C2 & C3) on 03/06/26 and 03/09/26. S1 and S2 both denied that children from day care have ever been sent upstairs, stating that they have a door/gate to prevent them from going upstairs.

During an interview with A1 on 02/04/26, A1 stated that their child told them that the Licensee (L1) let them go upstairs into L1’s child’s room. A1 stated that it was a big deal because their child told them more than once, talking about getting to color in L1’s child’s room. A1 figured it was special because upstairs was always off-limits.

Based on a review of records received by the Department on 12/19/25, A1 stated that when a Licensing inspector arrives, the provider instructs them to keep their child home or hides children in an upstairs bedroom to avoid being cited for being over capacity.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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 5
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: 03/12/2026
NARRATIVE
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On 03/06/26 LPA interviewed child (C2). During the interview C2 asked LPA, "Can I tell you something else?" and spontaneously offered the following information in summary: One time I was going to sleep, there was a couch and I had a blanket that I liked to use. I went to sleep on the couch in the room where the kids play. I woke up to someone taking me to a room in the house upstairs. I woke up on a bed. I woke up and went to another room, and I found other kids. The kids were upstairs because there were inspectors for daycare and Jackie wasn’t there and they told me we couldn’t go down there because Jackie would lose her license. The rest of the kids were in Jackie’s bedroom. Jackie’s child told me to be quiet. It was her younger child that told me. After the inspector left we went downstairs. It was at least 30 minutes to an hour and 30 minutes.

On 03/09/26 LPA interview child (C3), when asked if C3 remembered a time that they went upstairs, C3 stated that they never went upstairs in Ms. Jackie’s house. C3 informed LPA that teacher Jackie’s kids’ room is upstairs.

At 10:56am during today's visit L1 made the following statement, The children are not allowed upstairs. There is only one child that I allow upstairs, and that is (C5). (C5) is a good friend of my youngest child. She behaves and she is the only child that I allow upstairs.

Based on file review the local licensing regional office received a fire clearance on 09/04/2019 from the facilities local fire department for the facility, stating “special conditions” to include “Serving children ages 2 months to 12 years. See facility sketch.” Based on file review the facility sketch indicates that the “Entire 2nd floor is off-limits.”, therefore facility fire clearance does not include the 2nd floor and the facility was not authorized to use the second floor for child care.

Based on interview and record review, the following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given to licensee and must remain posted for 30 days.

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

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 03/12/2026
NARRATIVE
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LPA Strother informed licensee Jackielyn Bausely that this report dated 03/12/26 documents 1 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 03/12/26 that documents any 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.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/12/2026 12:10 PM - It Cannot Be Edited


Created By: Amy Strother On 03/12/2026 at 08:50 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: 03/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2026
Section Cited
CCR
102371(a)

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Fire Safety Clearance (a) A fire safety clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal shall be required for a large family child care home.


This requirement is not met as evidenced by:
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Licensee will submit a written statement of her understanding that the second floor of the home is not to be occupied by children in care at anytime and that she has reviewed the statement with all assistants working with children in care.
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Based on interview with A1 C2 and L1 the licensee did not comply with the section cited above, as daycare children were brought to the off-limits second floor of the home, which poses an immediate health, safety or personal rights risk to persons in care.
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Statement to be emailed to LPA Strother: amy.strother@dss.ca.gov.

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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: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
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