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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 283008881
Report Date: 02/01/2023
Date Signed: 02/01/2023 10:49:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2022 and conducted by Evaluator Melchisedeck Augustin
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20221014150940
FACILITY NAME:WISNIEWSKI, JACQUELINE FCCHFACILITY NUMBER:
283008881
ADMINISTRATOR:WISNIEWSKI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 306-2491
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:14CENSUS: 7DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jacqueline Wisniewski - LicenseeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Licensee did not provide full licensing report to parent(s)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Melchisedeck Augustin made a subsequent complaint-investigation visit and met with Licensee, Jacqueline Wisniewski (LS) for the purpose of delivering finding for the above allegation. LPA previously met with LS on 10/21/22 to initiate the investigation by discussing the purpose of the visit, conducted interviews with LS and staff, making observations; and requested a facility roster of the children currently in care. It was alleged that the Licensee did not provide the full licensing report to parent(s). The report noted LS did not provide a page of the 10/05/22 licensing report which contained pertinent detailed information about the complaint that resulted in a Type A citation.

LPA, Augustin interviewed LS and one staff (S1), three children (C1-C3), six adults (A1-A6), and four parents (P1-P4), from 10/20/22 through 01/24/23. Some children were not verbal, too young to interview, or did not qualify to be interviewed. The statement LS provided denied claims about her not providing all copies of the licensing report to parent(s) and LS stated she posted a full copy of the 10/05/22 substantiated Complaint Investigation Report (CIR). (Continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 01-CC-20221014150940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
VISIT DATE: 02/01/2023
NARRATIVE
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LS further claimed that on 10/05/22, she provided all three pages of the CIR which referenced the immediate risk violation; as well as obtaining parents’ signatures on the Acknowledgement of Receipt of Licensing Reports (LIC 9224). Statement provided by staff (S1) indicated S1 was present for a brief period on the day the Department delivered the CIR that cited the immediate risk violation.

Although P4 affirmed receiving a copy of the licensing report, A1, P2 & P3 confirmed they did not receive a physical copy of the full licensing report and LS only provided P2 & P3 with a verbal notification of the 10/05/22 complaint. Secondly, P2 expressed that although he/she did not receive the physical report, LS instructed P2 to convey to the Department that he/she was notified of the complaint. A1, P2, & P3 did acknowledge that they signed the Acknowledgement of Receipt of Licensing Reports (LIC9224) even though they all did not receive the full written report. A1 further described that LS did not provide the narrative page of the licensing report which contained the full details of the investigation and A1 had to obtain a full copy of the report on the Department’s transparency website which differed from the verbal details LS provided.

On 10/21/22, LPA reviewed children’s records which showed the LIC 9224 contained parent’s signature, but statements confirmed that LS did not provide the full written report to all parents resulting in the non-compliance of Health and Safety Code (H&SC) 1596.8595(c)(1) which mandates the facility to provide the parents or guardians of each child receiving services in the facility, copies of any licensing report that documents any Type A citation.

Based on LPAs investigation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Health and Safety Code, Title 22, Division 6 & Chapter 3.4 of the California Day Care Act, is being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 01-CC-20221014150940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
HSC
1596.8595(c)(1)
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A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of
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Licensee stated she would produce a written plan detailing how she would ensure that parents received a full physical copy of the licensing reports which ctie a type A violation and the Licensee intends to submit her written plan to the Department by 02/15/23 via mail, email or fax.
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subdivision (a) of Section 1596.893b.

This requirement is not met as evidenced by: Based on statements confirming LS did not provide the full written report to all parents. This posed a potential health, safety and/or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
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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.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2022 and conducted by Evaluator Melchisedeck Augustin
COMPLAINT CONTROL NUMBER: 01-CC-20221014150940

FACILITY NAME:WISNIEWSKI, JACQUELINE FCCHFACILITY NUMBER:
283008881
ADMINISTRATOR:WISNIEWSKI, JACQUELINEFACILITY TYPE:
810
ADDRESS:3790 OXFORD STREETTELEPHONE:
(415) 306-2491
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:7CENSUS: 7DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jacqueline Wisniewski - LicenseeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Licensee handled child inappropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Melchisedeck Augustin made a subsequent complaint-investigation visit and met with Licensee, Jacqueline Wisniewski (LS) for the purpose of delivering finding for the above allegation. LPA previously met with LS on 10/21/22 to initiate the investigation by discussing the purpose of the visit, conducting interviews with LS and staff, making observations; and requesting a facility roster of the children currently in care. It was alleged that the Licensee handled a child inappropriately. The report noted LS allegedly pulled a child’s (C1) ear when C1 did not want to take a nap resulting in C1 crying.

LPA, Augustin interviewed LS and one staff (S1), three children (C1-C3), six adults (A1-A6), and four parents (P1-P4), from 10/20/22 through 01/24/23. Some children were not verbal, too young to interview, or did not qualify to be interviewed. The statement LS provided, denied claims of her pulling any child(ren)’s ear, including C1, but that some children’s ears were red due to child(ren) either sleeping on their ear or some children had ear infections resulting in them pulling on their own ear(s). According to staff (S1), she had not witnessed LS pull on any child’s ear and she did not see any child(ren) rubbing their ear as if they were in pain. (Continue to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 01-CC-20221014150940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
VISIT DATE: 02/01/2023
NARRATIVE
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Multiple statements provided by adult (A5) and parents (P1-P4) reported they had not seen LS hit, scream, or pulled any child(ren)’s ear but A6 alleged that LS pulled another child’s ear, however, it could not be confirmed as there were no witnesses to this incident.

Based on LPA’s investigation, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation occurred, therefore the above allegation is found to be UNSUBSTANTIATED. Exit interview conducted, and report was reviewed with the licensee, Jacqueline Wisniewski. Appeal rights were provided. 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.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5