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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 09/20/2023
Date Signed: 09/20/2023 02:52:31 PM

Document Has Been Signed on 09/20/2023 02:52 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: 22CENSUS: 14DATE:
09/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Monisa Sediqi - LicenseeTIME COMPLETED:
03:15 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 8/30/2023 LS was cited one Type A deficiency as a result of a substantiated complaint allegation which alleged an excluded adult was providing care and supervision to the daycare children, and three type B for incomplete facility roster, S1's record did not contain evidence of required Immunization Record (IR), and the children's records were incomplete.

During today's visit, LPAs counted and observed fourteen children (C1-C14) which consisted of eight children (C5, C7-C10, C11-C13) under 24 months old in the care of LS and S1. The facility was out of ratio and did not comply with the requirements of Health and Safety Code (HSC) 1597.465(b) which indicates no more than three infants are cared for during any time when more than 12 children are being cared for.

Furthermore, LPAs observed the report which cited a type A deficiency on 08/30/23 was not posted and the off limit garage was fully furnished with various child care equipment such as diapers, child size chairs, mats, cubbies, and high chair. Furthermore, LPAs observed a bouncer and walker in the garage. LS denied that she was/had provided care in the garage and also denied that daycare children used the walker and/or bouncer. LPAs reminded LS that the garage was not approved by the Fire Department to provide care and supervision to children and LS was reminded that bouncer and walkers were prohibited to use in a licensed Family Child Care Home (FCCH). LS stated she understood the requirements and appeared to have acknowledged LPAs' statements. LPAs reviewed fourteen children's (C1-C14) records at 9:25am which revealed C1-C14 either had an incomplete or missing licensing forms such as LIC 282, 627, 700, 9150, 9224, Immunization Records (IR) or IR was not transcribed onto the blue CDPH 286. Additionally, C7-C8, & C12's records did not contain the Individual Infant Sleep Plan (LIC 9227). (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/20/2023 02:52 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/20/2023 at 12:07 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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2023
Section Cited
HSC
1597.465(b)

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No more than three infants are cared for during any time when more than 12 children are being cared for.

This requirement is not met as evidenced by: Based on LPAs observation and record review at 9:25 am that confirmed that there were
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Licensee stated she would contact families and coordinate transfer of the infants to another facility, and Licensee would produce a written plan detailing how she intends to reduce the number of infants to comply with Health and Safety Code 1597.465(b).
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8 infants in care. This posses an immediate health, safety and/or personal rights risk to the children in care.
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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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


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Document Has Been Signed on 09/20/2023 02:52 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/20/2023 at 12:14 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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
102425(j)(2)(D)(c)

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Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check.

This requirement was not met as evidenced by: Based on Licensee not furnishing evidence to prove she conducted 15 minute checks for
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Licensee stated she would initiate and document 15 minute checks for C5, C7-C10 & C11-C13, and submit seven days worth of 15 minute checks to the Department by 09/29/23 via mail, email or fax.
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C5, C7-C10, C11-C13 while they nap/sleep.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
09/29/2023
Section Cited
HSC1596.8595(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
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Licensee stated she would provided and obtain parental signature on the LIC 9224, as well as a copy of the report citing a type A deficiency, and place the signed forms in each child's record. Licensee stated she would produce a written plan detailing how she intends to comply with HSC 1596.8595(c)(1).
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subdivision (a) of Section 1596.893b

This requirement was not met as evidenced by: Based on LPAs review of fourteen (C1-C14) children's records which revealed C2-C3, C7-C11 & C13-C14 were missing LIC 9224. This poses/posed a potential health, safety and/or personal rights risk to the 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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


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Document Has Been Signed on 09/20/2023 02:52 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/20/2023 at 12:38 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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
HSC
1596.8595(a)(1)

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Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to
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Licensee stated she would post all required reports, LPAs provided a copy of today's report, as well as report which cited a type A on 08/30/23. Prior to LPAs's departure, LPA observed both reports as mentioned above were posted.
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Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days.

This requirement was not met as evidenced by: Based on LPAs' observations of the report which cited type A on 08/30/23 was not posted, and an immediate $100 civil penalty was assessed. This poses/posed a potential health, safety and/or personal rights risk to the children in care.
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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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


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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: 09/20/2023
NARRATIVE
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Furthermore, LS did not furnish evidence to prove she conducted 15 minutes checks while C5, C7-C10, C11-C13 took a nap/sleep. LS stated she was unaware of all the required forms and LS requested an extension on her POC due date. The Department granted LS an extension on her POC due date and LS will has until 09/25/23 to submit evidence to prove the children's records are complete. LPAs reminded LS that if her POC is not received by 09/25/23, the facility may be assessed a civil penalty for failure to correct. Furthermore, an immediate $100 civil penalty was assessed because LS did not comply with posting requirements as specified in HSC 1595.8595(a)(1).

On 09/07/23 & 09/12/23, LS submitted evidence of required IR for S1 and a completed facility roster of the children currently in care. LPAs cleared deficiency related to incomplete facility roster and provided LS with a copy of the POC clearance letter.

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. Exit interview conducted and report was reviewed with the licensee, Monisa Sediqi. The following violation of California Code of Regulations, Title 22, Division 12, was cited during today's visit. Appeal Rights were provided.

LPAs, Melchisedeck Augustin and Selena Mariani informed licensee, Monisa Sediqi that this report dated 09/20/2023 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 09/20/2023 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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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