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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:08:24 PM

Document Has Been Signed on 10/27/2023 12:08 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: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: 15CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Monisa SediqiTIME COMPLETED:
12:20 PM
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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 10/18/2023, 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 a type B deficiency for not ensuring that the children's records were complete.

During today's visit, LPAs counted and observed six children (C1,C3, C4, C7, C13 & C14) which consisted of two children (C13-14) under 24 months old in the care of LS and Staff (S1). The facility was complying with ratio requirements of Health and Safety Code (HSC) 1597.465(b). Secondly, LPAs observed the report dated 10/18/2023 which cited a Type A violation was posted on the board in the living room.

Furthermore, LPAs observed a plastic door knob cover installed on the door knob to the off limit garage and didn't observe any children playing in the garage. LPAs requested to review fifteen children's (C1-C15) records at 8:52am, however; C1-C15 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 9/21/23, Immunization Records (IR). The records indicated C1-C15's parents had not been notified of reports which cited Type A deficiencies. LS provided evidence of 15 minutes sleep checks for two children (C13 & C14).
(Continue to LIC 809-C)
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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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: SEDIQI, MONISA FCCH
FACILITY NUMBER: 483010241
VISIT DATE: 10/27/2023
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On 10/19/23, LS submitted a written plan which indicated on how she will comply with ratio requirements. LPAs provided LS with a copy of the Plan of Corrections (POC) clearance letters. LPA's assessed a civil penalty of $800 because LS did not ensure that the children's records were complete.

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. Appeal Rights were provided.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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