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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 03:04:36 PM

Document Has Been Signed on 12/21/2023 03:04 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:WISNIEWSKI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 306-2491
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Jacqueline WisniewskiTIME COMPLETED:
03:18 PM
NARRATIVE
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During the course of a complaint investigation, an additional deficiency was identified based on evidence showing parents or guardians of each child currently receiving services were not provided a copy of the licensing report which documented a Type A citation that represented an immediate risk to the health, safety, or personal rights of children in care. From 11/15/2023 through 12/08/2023, interviews were conducted with the Licensee (L1) and nine adults (A1-A9), and documents obtained pertaining to the investigation.

In addition to five parents or guardians not being provided the report with the Type A violation at time of enrollment, at least four parents (A2, A4, A7, A8) of children, who were currently enrolled and receiving services at the time of the violation, confirmed they did not receive the Type A licensing report stating either they were never given a report to read or that they were verbally told about the Type A violation, but not given the report to read.



The following violation of the Health and Safety Code was issued: see LIC 809D. A civil penalty in the amount of $250 is being assessed on form LIC421FC for a repeat violation within a 12 month period. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
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)
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Document Has Been Signed on 12/21/2023 03:04 PM - It Cannot Be Edited


Created By: Melinda Mohr On 12/21/2023 at 01:10 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: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
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 subdivision (a) of Section 1596.893b.
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Licensee stated she would produce a written plan detailing how she would ensure that parents of children receiving services will receive a full physical copy of the licensing reports which cite a type A violation.
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This requirement is not met as evidenced by: Based on statements confirming L1 did not provide the full written report to all parents of children receiving services. This posed a potential health, safety and/or personal rights risk to the children in care.
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Licensee will submit her written plan to LPA Mohr via mail, fax or email : melinda.mohr@dss.ca.gov

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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 Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
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)
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