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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 06/02/2026
Date Signed: 06/02/2026 04:36:09 PM

Document Has Been Signed on 06/02/2026 04:36 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: 23CENSUS: 7DATE:
06/02/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:24 PM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother made an unannounced visit to the facility, arriving at 12:45pm. Upon arrival, LPA rang the doorbell. Assistant S2 open the front door to a closed metal security screen. Licensee, Jackielyn Bausley (L1) came to the security screen. LPA observed L1 use a laminated paper, sliding it along the screen door knob mechanism to open the screen to allow LPA to enter.

LPA sat in the living room with assistants S1 and S2 who were supervising 7 children in care. Later during the visit, L1 invited LPA to come into the dining room to sit at the table to review records. At 2:50pm LPA requested to go outside to make a phone call. As LPA exited the dining area, LPA passed through the family room, observing a low coffee table with several prescription medication on it. Although the children were contained in the living room during the inspection with a child safety gate making the family room inaccessible, the only downstairs bathroom is on the family room side of the safety gate.

LPA asked assistant S1 if any of the children in care use bathroom or if all children are in diapers. S1 stated that two children, C1 and C2 wear underwear and use the bathroom. When C1 and C2 use the bathroom the medications in the family room are accessible. L1 confirmed that C1 and C2 use the bathroom.

When LPA attempted to exit the home out the front door, LPA was not able to open the metal security screen. LPA twisted the lock on the knob of the screen and was still unable to open the screen door. Assistant S2 came over to the door, using the laminated piece of paper, sliding it along the door knob, opened the screen door, allowing LPA to exit.

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)
Page: 1 of 4
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
NARRATIVE
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The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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

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

LPA Strother informed licensee that this report dated 06/02/26 document(s) two Type A citation(s) which shall be posted for 30 consecutive days as there 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 06/02/26 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: 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)
Page: 4 of 4
Document Has Been Signed on 06/02/2026 04:36 PM - It Cannot Be Edited


Created By: Amy Strother On 06/02/2026 at 03:53 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: 06/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2026
Section Cited
CCR
102417(g)

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(g)The home shall be free from defects or conditions which might endanger a child...




This requirement is not met as evidenced by:
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Licensee stated that will leave the security screen open and then replace the door knob on the security screen door and submit a video of the screen knob in operating condition by text message to LPA Strother by 06/03/26. Video text to be sent to (707)599-1479.
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Based on observation the metal security screen door is kept closed and is not in operating condition, and not able to open without using an alternative means, in this case a laminated piece of paper, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/03/2026
Section Cited
CCR102417(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...which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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During today's visit, L1 moved the medications to a tall filing cabinet, making them inaccessible. L1 stated she may move medications to a top cabinet in the kitchen at a later date.
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Based on observation medications were located in an area of the home that is listed as on-limits and accessible to children who are potty trained and use the bathroom on the side of a child safety gate where the medication where observed on a low table, 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2026


LIC809 (FAS) - (06/04)
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