283008881-9-3-2026-01-CC-JGAN-DXKT4W-20260903142438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 283008881
Report Date: 09/03/2026
Date Signed: 09/03/2026 02:24:58 PM

Document Has Been Signed on 09/03/2026 02:24 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:	WISNIEWSKI, JACQUELINE FCCH		FACILITY NUMBER:	283008881
ADMINISTRATOR/ DIRECTOR:	WISNIEWSKI, JACQUELINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 306-2491
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 6	DATE:	09/03/2026
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:49 AM
MET WITH:	Jacqueline Wisniewski		TIME VISIT/ INSPECTION COMPLETED:	02:26 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	An annual required inspection was made to the facility by Licensing Program Analysts (LPAs), Jessica Gaumann and Sebastian Phouthavong. LPAs met with Licensee Jacqueline Wisniewski. Licensee was reminded that all adults 18 and over living or working in the home, 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. During the inspection the home was toured inside and outside. The licensee was supervising 6 children and operating within the licensed capacity and ratio requirements. Licensee provided a current roster of children in care as required. LPA Gaumann verified that the children present were listed on the roster. The facility’s operating hours are Monday – Friday, 7:30am - 5:30pm. The floor plan submitted by the licensee was reviewed and verified. The on-limits areas are the living room, kitchen, three bedrooms, hallway bathroom and backyard. The off-limits area of the home is the garage which was made inaccessible by a 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. Licensee’s pediatric CPR and First Aid certifications were reviewed and expire in 10/2026. Continued on LIC 809-C

Melinda Mohr
Jessica Gaumann
	DATE: 09/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

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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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)

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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: WISNIEWSKI, JACQUELINE FCCH	FACILITY NUMBER: 283008881
	VISIT DATE: 09/03/2026

NARRATIVE

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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 all poisons on the premises are in a key locked cabinet in the garage. LPA Gaumann observed the cabinet to be locked and the garage was inaccessible to children in care by way of a locking latch at the top of the door. LPAs observed a working smoke detector, carbon monoxide detector and a fire extinguisher that appeared to be charged, rated at least 2A10BC, in the home. Licensee has conducted an emergency drill within the past six months; last drill was documented on 05/29/2026. Licensee stated there are no firearms or dangerous weapons in the home and none were observed. There were no swimming pools or other bodies of water observed on the property. Five children's records were reviewed. Facility and personnel files were reviewed and contained required records. Licensee furnished evidence of completion of current AB 1207 Mandated Reporter Training which expires in 02/2027 and all required immunizations were provided.

LPAs 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. LPAs also informed licensee of the importance of checking for and removing any 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.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Jessica Gaumann
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC809 (FAS) - (06/04)

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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: WISNIEWSKI, JACQUELINE FCCH	FACILITY NUMBER: 283008881
	VISIT DATE: 09/03/2026

NARRATIVE

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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 violations of California Code of Regulations, Title 22, was cited on the attached LIC 809-D page. 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 Licensee Jacqueline Wisniewski.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Jessica Gaumann
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/03/2026 02:24 PM - It Cannot Be Edited

Created By: Jessica Gaumann On 09/03/2026 at 02:06 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: 09/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that C1, C3 and C4's CDPH 286 forms were missing immunizations according to the immunization records provided in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2026
	Plan of Correction
1 2 3 4	Licensee stated she will obtain updated immunization records for C1, C3 andC4's files and update their CDPH 286 forms. Due to children's confidentality, Licensee will submit a statement stating she has received updated immunization records and the children's CDPH 286 cards have been updated to LPA Gaumann via email: jessica.gaumann@dss.ca.gov by 09/24/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:

	Jessica Gaumann
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC809 (FAS) - (06/04)

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