493009498-6-2-2026-01-CC-ASTR-DUP22M-20260602170059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 06/02/2026
Date Signed: 06/02/2026 05:01:21 PM

Document Has Been Signed on 06/02/2026 05:01 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 FCCH		FACILITY NUMBER:	493009498
ADMINISTRATOR/ DIRECTOR:	BAUSLEY, JACKIELYN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 888-5130
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 23	CENSUS: 7	DATE:	06/02/2026
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Jackielyn Bausley		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE

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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 A deficiencies that were cited on 03/12/26. L1 was cited during a Case Management – Deficiencies visit on 03/12/26 for allowing children in care to enter the off-limits second floor of the home, which is not included in the facility fire clearance. The POC for this citation was due 03/13/26 and has not been received. L1 was cited 6 citations on a Complaint Investigation Report, also dated 03/12/26. Four out of the six citations have been cleared. Two of the 6 citations, both Type A citations for violation of Children’s Personal Rights, involving staff, have not yet been cleared. Although L1 did submit a POC on 03/13/26, for the Personal Rights violations, the POC’s did not meet a measurable standard, and LPA could not determine specifically how the Licensee would attain compliance.

During today's visit, L1 provided a statement that she and her assistants understand that the 2nd floor of the home is off-limits to children in day care. L1 also provided a written statement that she has read and follows the children's personal rights regulations, has read and translated the regulations for her assistants, will model the regulations and provide guidance to her assistance as needed. The above citations were cleared during today's visit.

Additionally, the visit was for the purpose of following up on nine Type B deficiencies that were cited on 05/06/26, during an Annual/Required visit. One Type B citation was issued due to the licensee’s absence exceeding 20% of the hours that the facility provides care per day.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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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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: 06/02/2026

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The remaining eight citations were all paperwork related: lack of disaster drill log, personnel records containing signed employee rights form for staff S1 and S2 present on 05/06/26, and children’s records for children C1 and C2 containing the following: infant sleep log for infant C1, signed Affidavit regarding liability insurance, immunization records, emergency cards, proof that Notice of Parents Rights, and signed form LIC9224 acknowledging Type A citations received on 03/12/26 and 07/17/25.

On 05/20/26 L1 submitted a statement that on days that L1 cannot be present, her assistants will not provide care for the children of more than one family.

L1 submitted statements outlining how she would provide access to all required licensing records to provide to the Department in her absence. On 05/20/26 L1 submitted documentation of disaster drill conducted last on 12/30/25 at 9:00am.

During today’s inspection LPA reviewed files for assistants S1 and S2. LPA observed signed and dated copies of the Notice of Employee Rights, form LIC9052.

LPA reviewed files for children C1-C2 who were present on 05/06/26 and three additional children’s files for children C3-C5, present during today’s inspection. During record review, LPA observed a completed sleep log for infant C1, signed affidavits, form LIC282 for C1-C5, current immunization records and form CDPH 286 for children C1-C3 and C5, child C4’s file did not contain a copy of immunization records or form CDPH 286. Emergency cards/form LIC700 was observed to be in files for C1-C5, as well as signed Notice of Parents Rights, form LIC995A. Signed form LIC9224 acknowledging Type A citations received on 03/12/26 was observed in C1-C5’s files. Signed form LIC9224 acknowledging Type A citations received on 07/17/25 was not observed in C1-C5’s files. Seven out of 9 citations were cleared during today's visit.

In accordance with California Code of Regulations (CCR), 101195(f), the Department is assessing a Civil Penalty of $100 per day for period of 05/21/26 through 06/02/26 because the Licensee did not correct two of the deficiencies by the plan of correction date, in the amount of $1300 each, for a total of $2600. See LIC421FC.

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. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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