<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 07/07/2026
Date Signed: 07/07/2026 02:15:33 PM

Document Has Been Signed on 07/07/2026 02:15 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: 13CENSUS: 2DATE:
07/07/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:53 AM
MET WITH:Jackielyn BausleyTIME VISIT/
INSPECTION COMPLETED:
02:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Robert Maciel-Kashima and Licensing Program Manager (LPM) Melchisedeck Augustin made an unannounced case management visit and met with Licensee Jackielyn Bausley (LS) to verify status of adults that were immediately excluded from the facility. The order for exclusion requires that two adults (A1 & A2) may not come into contact with any clients of the facility and may not be physically present in the home. On 7/1/26, the department served letters of immediate exclusion of adults from the facility.

During today's visit, LPA and LPM observed 2 children in the care of LS. It is noted that there were two other adults (A3 & A4) in the home. LPA and LPM interviewed LS and A4. LS stated that A1 and A2 left the facility the evening of 7/4/26 and do not provide assistance with childcare. Licensee provided current home address of A1 and A2. A4 claimed that they were a visitor but did not reside in the facility and provided their current address. A4 reported that they enter the home through the garage, not through the front door. A4 claimed that they did not see A1 or A2 in the home since arriving on 6/30/26.

Licensee provided LPA and LPM consent to tour the entire home which consisted of the living room and half-bath, which are on-limits, and the family room, the kitchen, the garage, the backyard, the second floor loft, all three second floor bedrooms, and the second floor bathroom, which are all off-limits, to verify the presence of A1 and A2 in the home. LPA and LPM did not see or find evidence to suggest that A1 and A2 were residing in the home.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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)
Page: 2 of 4
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: 07/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA and LPM reviewed the facility roster to verify the total number of children enrolled. There are a total of 13 children in care. LPA and LPM also reviewed 12 children's records, excluding the Licensee's own children, which revealed that the records did not contain the LIC995B Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion) form. Based on Licensee's statement, she had left the facility on 7/1/26 and returned to the facility on 7/4/26. Licensee confirmed that since her return on 7/4/26, only two children (C1 & C2) were in care on 7/6/26 and 7/7/26. LPA and LPM reminded LS of the importance of complying with the immediate exclusion order. LS was advised that A1 and A2 may not come into contact with children and may not reside in the home. Any violation of the immediate exclusion order will result in civil penalties for violation of criminal record clearance.

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.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/07/2026 02:15 PM - It Cannot Be Edited


Created By: Robert Maciel On 07/07/2026 at 01:58 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: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2026
Section Cited
CCR
102419(h)

1
2
3
4
5
6
7
The licensee shall provide a copy of the Department Issued Addendum to Notification of Parent's Rights (Regarding Removal/Exclusion) (LIC 995B Rev. 05/03) sent by the Department, that is still in effect, to one parent or authorized representative of every child when the parent or authorized representative arranges for child care services or on the first day the child receives care, whichever is first.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
During the visit, a parent of child 1 dropped off a signed LIC995B. Licensee stated that she would ensure parents are notified of A1 and A2's immediate exclusion order and would obtain signatures on the LIC995B and place it in each child's record and submit a copy of each complete form to LPA by email at [email protected] by 7/17/26
8
9
10
11
12
13
14
Based on review of children records, the records for child 1 and child 2 were missing signed copies of Addendum to Notification of Parents’ Rights form LIC 995B. This posed a potential health, safety and/or personal rights risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4