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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:13:10 PM

Document Has Been Signed on 11/01/2023 03:13 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: 17CENSUS: 8DATE:
11/01/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Monisa SediqiTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Selena Mariani conducted an unannounced Plan of Correction (POC) visit and met with Licensee (LS) Monisa Sediqi to follow up on prior outstanding deficiencies for not ensuring that the children's records were complete.

During today's visit, LPA counted and observed eight children (C1-C8) which consisted of two children (C6 & C8) under 24 months old in the care of LS and Staff (S1). LPA requested to review seventeen children's (C1-C17) records at 12:30pm. Children's files for (C3, C5, C11-C14) were complete. LS provided evidence of 15 minutes sleep checks for two children (C6 & C7) under 24 months old.

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: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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