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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008881
Report Date: 05/06/2025
Date Signed: 05/06/2025 01:04:53 PM

Document Has Been Signed on 05/06/2025 01:04 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/
DIRECTOR:		WISNIEWSKI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 306-2491
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
05/06/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jacqueline WisniewskiTIME VISIT/
INSPECTION COMPLETED:
01:15 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), Mindy Mohr made an unannounced Legal/Non-compliance Case Management visit and met with Licensee, Jacqueline Wisniewski, to ensure compliance with the terms set during a prior Non-Compliance Conference (NCC) on 01/31/2025. At the time of the NCC, the Licensee agreed to adhere to the following terms to bring the facility into compliance:
  • Licensee and staff will follow the requirements of infant safe sleep to include the door to the infant sleeping room shall remain open at all times and 15-minute sleep checks shall be maintained for all infants in care.
  • Licensee will ensure children in care are supervised at all times and that curtains to the living room will remain open except while all children are sleeping.
  • Licensee will not place children in cribs in a separate room for the purpose of discipline method for the children to calm down.
  • Licensee understands the cubbies intended use is to store children's. Eight out of the thirteen cubbies have a small bench which allows children to remove and put on shoes and not as a place to sit for an extended period of time or for discipline purposes unless a child voluntarily chooses to sit in the cubby.
  • Licensee and staff will comply with children's personal rights by attending to their needs and will comfort them when upset, crying, or ill.
  • Licensee will provide all reports documenting a Type A deficiency within a 12 month period to all parents of children currently in care as well as newly enrolled children.
(continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Melinda Mohr
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 3
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 3
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: 05/06/2025
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
  • Licensee understands parents have a right to enter the facility at any given time during the hours of operation.
  • Licensee agrees to cooperate with all CCL's complaint investigations and inspection authority.
  • Participate in CCL's Technical Support Program (TSP).


During todays visit Licensee was operating within the ratio and capacity requirements, Licensee (L1) and her assistant were supervising 10 children. Upon arrival LPA observed the curtain to the living was open. LPA observed the door where the infants sleep to be open with three cribs in the room. There were no children sleeping. L1 stated the door to the room stays open while the children are sleeping, and the only time children are in the room is when they are asleep. LPA reviewed the 15 minute sleep logs were maintained and up to date. L1 stated the children only sit in their cubbies to take off their shoes in the morning. L1 also stated if a child is crying or upset they tend to the child immediately by holding the child and giving the child encouraging words. L1 stated parents drop off and pick up their children either inside at the baby gate leading to the living room, or at the front door. Parents can choose where to drop off and pick up their children. LPA reviewed children's files (C1-C10), all files contained a signed Acknowledgment of Receipt of Licensing Reports LIC9227 as required.

The facility has completed all training's with CCLD’s Technical Support Program (TSP). Based on today's visit, the facility appeared to be complying with the terms of the NCC.

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. There were no violation(s) of the California Code of Regulations, Title 22; Division 12, cited during today's visit.

NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Melinda Mohr
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3