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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008881
Report Date: 10/03/2024
Date Signed: 10/03/2024 05:14:56 PM

Document Has Been Signed on 10/03/2024 05:14 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: 11DATE:
10/03/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Jacqueline Wisniewski TIME VISIT/
INSPECTION COMPLETED:
05:24 PM
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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. Upon LPAs arrival the assistant was supervising 11 children alone and LPA observed one bedroom door closed with 2 infants sleeping in the room. The facility’s operating hours are Monday - Friday 7:30 AM - 5:30 PM. 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 expired 09/2024. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be accessible to children in the bathroom.



Continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
VISIT DATE: 10/03/2024
NARRATIVE
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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 06/24/2024. Licensee stated to not have any firearms and/or other dangerous weapons and none were observed during the inspection. The home's yard is fully fenced. There were no pools or other bodies of water observed. Eleven 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.

Continued on LIC 809-C

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WISNIEWSKI, JACQUELINE FCCH
FACILITY NUMBER: 283008881
VISIT DATE: 10/03/2024
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 violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. An immediate $250.00 civil penalty is being cited today. 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.

LPA Mohr informed Licensee that this report dated 10/03/2024 documents a Type A citation. Type A citations shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

LPA Mohr informed Licensee to provide a copy of this licensing report dated 10/03/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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Page: 6 of 6
Document Has Been Signed on 10/03/2024 05:14 PM - It Cannot Be Edited


Created By: Melinda Mohr On 10/03/2024 at 04:20 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: 10/03/2024

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 one room did not have the door open while two infants C1 & C11 were sleeping inside, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee stated they will keep the door all the way open to check on the 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 Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 05:14 PM - It Cannot Be Edited


Created By: Melinda Mohr On 10/03/2024 at 04:20 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 the bathroom had disinfecting wipes on the sink which was accessible to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee corrected the violation immediately by removing the cleaning products. Licensee stated the cleaning supplies are usually up and out of the reach of children, but they must have forgotten to put them up. Licensee will keep all cleaning supplies up and out of the reach of the children.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in which 2 children (C1 & C7) did not have up to date sleep logs available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee stated she must have thrown the sleep logs aways by accident. Licensee stated she will keep up with the sleep logs everyday the children are in care.
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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/03/2024 05:14 PM - It Cannot Be Edited


Created By: Melinda Mohr On 10/03/2024 at 04:20 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

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. Upon LPA's arrival the Licensee was not home and the assistant was supervising 11 children alone for approximately 25 minutes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee stated she will not leave the facility if there are more than 6 children present, she will pick up her son later in the day. Licensee will send LPA Mohr a written statement stating she will always be within ratio to Melinda.mohr@dss.ca.gov
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 Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


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