<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 10/18/2023
Date Signed: 10/18/2023 05:18:45 PM

Document Has Been Signed on 10/18/2023 05:18 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: 11DATE:
10/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Monisa SediqiTIME COMPLETED:
05:30 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
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 9/20/2023, LS was cited one Type A deficiency as a result of providing care for more than three infants when more than 12 children are being cared for, and three Type B deficiencies for not having evidence to prove she conducted 15 minute checks while C5, C7-C13 napped, not notifying parents of having received a Type A violation on 8/30/23 and not posting the report which cited a Type A deficiency.

During today's visit, LPAs counted and observed eleven children (C1-C6, C8 & C10-C13) which consisted of five children (C5, C8, C11-13) 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 four infants are cared for during any time when less than 12 children are being cared for. Secondly, LPAs observed the report dated 09/20/2023 which cited a Type A violation was posted on the board in the living room.

Furthermore, LPAs observed the off limit garage was fully furnished with various child care equipment such as child size table, couch and chairs, mats, napping cots, cubbies, high chair, bouncer and walker. 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 requested to review seventeen children's (C1-C17) records at 11:46am, however; LS did not provide a records for C2, C10 and C11. C1, C3-C9, C12-C17 either had an incomplete and/or missing licensing forms such as LIC 282, 627, 700, 9150, 9224 for 6/1/23, 8/30/23 and 9/30/23, Immunization Records (IR). Additionally, C11-C13 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: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 10/18/2023
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
26
27
28
29
30
31
32
On 09/21/23 & 09/29/23, LS submitted evidence to show she initiated 15 minutes Sleep Checks for C5, C8, C12 & C13. LPAs cleared deficiency related to Health and Safety Code 1597.465(b) and 1596.8595(a)(1) 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 violations of California Code of Regulations, Title 22, Division 12, were cited during today's visit. Appeal Rights were provided.

LPAs, Melchisedeck Augustin and Selena Mariani informed licensee, Monisa Sediqi that this report dated 10/18/2023 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 10/18/2023 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: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/18/2023 05:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 10/18/2023 at 03:28 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
102416.5(d)(1)

1
2
3
4
5
6
7
102416.5 Staffing Ratio and Capacity For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: Twelve children, no more than four of whom may be infants.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated she will talk with the family to ensure there are only 4 infants present whenever there is less than twelve children in care. The Licensee would produce and submit a written statement indicating how she would arrange the children's schedules to demonstrate how the facility would comply with the ratio requirements.
8
9
10
11
12
13
14
Based on children's records review which confirm the children's age and LPAs observations of 5 infants in care during the visit.
This poses an immediate health, safety and/or personal rights risk to the children in care.
8
9
10
11
12
13
14
Licensee intends to submit her written statement to the Department by 10/19/23 via mail, email or fax.
Email to: selena.mariani@dss.ca.gov

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/18/2023 05:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 10/18/2023 at 03:54 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
102421(a)

1
2
3
4
5
6
7
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 C3, C10 & C11 in care.
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This poses a potential health, safety and/or personal rights risk to the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4