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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:01:48 PM

Document Has Been Signed on 08/30/2023 02:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SEDIQI, MONISA FCCHFACILITY NUMBER:
483010241
ADMINISTRATOR:MONISA S & DEHYAR TFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 999-6699
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
08/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Monisa SediqiTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mel Augustin and Selena Mariani conducted an unannounced Plan of Correction (POC) visit and met with Licensee (LS) Monisa Sediqi to follow up on prior outstanding deficiencies. On 6/1/2023 LS was cited two Type A deficiencies for operating over capacity and for not barricading staircase while children under 5 years of age were in care. Additionally, LS was cited three Type B deficiencies for not providing a facility roster of children in care, required immunization for S1 and incomplete children records.

During today's visit LPAs observed 14 children in care and the facility was compliant with staffing ratio and capacity requirements. Stairs near the front entrance was securely barricaded with child safety gate. LPAs requested a current facility roster and required immunization for S1 and children's records, however, LS did not furnish items requested. LPAs cleared deficiencies related to California Code of Regulation (CCR) 102416.5(a) and CCR 102417(g)(3) and provided LS with a POC clearance letter.

During an unannounced visit at Faiziar Maria FCCH # 483010251 on 8/23/23, LPA Mariani observed an adult without criminal record clearance (A2) picking up and loading C1 into her vehicle and at which time A2 confirmed she was transporting C1 to Sediqi, Monisa FCCH. Furthermore, LPA, Augustin conducted an interview with A2 on 8/24/23 which revealed that A2 had an agreement with LS to provide transportation services to a child in care. According to A2's statement, on at least one occasion she transported a child (C1) from Faiziar Maria FCCH to the facility on 8/23/23. An immediate $100 Civil Penalty is being assessed because LS did not assure A2 did not obtain a Department approved Criminal Background Clearance.

Title 22 deficiency is being cited on the attached 809-D. 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. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 08/30/2023 02:01 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2023 at 11:18 AM
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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption as required by the Department
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Licensee stated she would ensure all adults obtain a Department approved criminal record clearance prior to working or transporting daycare children.
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This requirement was not met as evidenced by: Based on interview conducted with A2 and LPAs observations confirming A2 transported C1 to the facility. An immediate $100 Civil Penalty was assessed because LS did not ensure A2 obtained clearance prior to transport.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

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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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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Document Has Been Signed on 08/30/2023 02:01 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2023 at 11:31 AM
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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2023
Section Cited
HSC
1596.841

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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing
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Licensee stated she will create a current roster and submit roster to the Department by 9/13/2023.
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agency upon request.

This requirement was not met as evidenced by: Based on Licensee did not furnish a complete roster of the children in care. This poses a potential health, safety and/or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
09/13/2023
Section Cited
HSC1597.622(a)(1)

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 Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee stated S1 will aquire immunization by 9/13/23 and submit to the Department.
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This requirement was not met as evidenced by: Based on Licensee did not provide required immunization record for S1. This poses a potential health, safety and/or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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Document Has Been Signed on 08/30/2023 02:01 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2023 at 11:37 AM
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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2023
Section Cited
CCR
102421(a)

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The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
This requirement was not met as evidenced by: Based on LS did not furnish children's records for any of the children in care.
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Licensee stated she would ensure created complete record with required licensing forms for each child, and Licensee intends to submit submit evidence showing completiong of the children's records.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

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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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241
VISIT DATE: 08/30/2023
NARRATIVE
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LPAs, Melchisedeck Augustin and Selena Mariani informed licensee, Monisa Sediqi that this report dated 08/30/2023 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPAs Melchisedeck Augustin and Selena Mariani informed the licensee to provide a copy of this licensing report dated 08/30/2023 that documents any Type A citation(s) 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: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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