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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008881
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:57:26 PM


Document Has Been Signed on 12/21/2023 02:57 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WISNIEWSKI, JACQUELINE FCCHFACILITY NUMBER:
283008881
ADMINISTRATOR:WISNIEWSKI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 306-2491
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:14CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jacqueline WisniewskiTIME COMPLETED:
01:30 PM
NARRATIVE
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Mindy Mohr. LPA met with Licensee, Jacqueline Wisniewski. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. There are currently 2 adults living in the home.

During the inspection the home was toured inside and outside. The licensee and assistant were supervising 6 children and operating within the licensed capacity and ratio requirements. Upon arrival LPA observed two bedroom doors closed with 2 infants sleeping in one room and 1 infant sleeping in the other room, which was discussed at an informal conference with Licensee on 05/11/2023. The facility’s operating hours are Monday - Friday 7:30AM - 5:30PM. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the living room, kitchen, three bedrooms and hallway bathroom. The off-limits areas of the home is the garage. The off-limits areas of the home was made inaccessible by a door lock and locking latch at the top of the door. The home appears to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire on 09/2024. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated that there are no poisons stored in the home and none were observed during today’s inspection. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months; last drill was documented on 12/11/2023.


Continued on LIC 809-C
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
VISIT DATE: 12/21/2023
NARRATIVE
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 Licensee stated to not have any firearms and/or other dangerous weapons and none were observed during the inspection. The home's backyard is fully fenced. The home's front yard is "off limits" with a play structure, slide and other outdoor play equipment. It was confirmed during today's inspection children use the play structure, slide and other equipment in the "off limits" area. There were no pools or other bodies of water observed. Six children's records were reviewed. Facility and personnel files were reviewed and contained required records.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, Jacqueline Wisniewski, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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 and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Jacqueline Wisniewski.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 12/21/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which two room had doors completely closed with three infants C3 -C5 sleeping in them which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2023
Plan of Correction
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Licensee has corrected the violation today by opening the doors to the bedrooms while the infants are asleep. Licensee stated they usually have the doors open, they forgot today.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 12/21/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in which children are allowed to use the front yard as an area to play which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Licensee has already updated her facility sketch. Licensee will also write out a plan to use the front yard, which will include how the Licensee and her assistants will superviise the children when they are playing as the front yard is not fenced in. The plan will also include the age of the children using the play structure as the Licensee acknowledged the play structure is not age appropriate for infants.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4