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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010241
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:22:09 PM

Document Has Been Signed on 06/01/2023 02:22 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: 0CENSUS: 15DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Monisa Sediqi - LicenseeTIME COMPLETED:
11:00 AM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analysts (LPAs), Melchisedeck Augustin and Selena Mariani made an unannounced Case Management visit and met with Licensee, Monisa Sediqi (LS), to deliver several deficiencies observed. At 9:51am, LPAs observed and counted 15 children in care with LS and S1, and LS was not complying with requirements of staffing and capacity ratio of California Code of Regulations (CCR) 102416.5(a) which indicates, the capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. Of the 15 children, three children under 24 months old were awake in play yards, four children were not eating a meal but were seated and secured in high chairs, and eight children were scattered and playing through the play room. It is noted that three children left the facility at 10:34am and an additional child left at 11:10am which brought the census to 11 children.

Furthermore, the child safety gate was not secured to the staircase in the living room and could easily be moved, LS did not furnish required immunization for S1, and the facility roster was incomplete. There were 15 children in care, however, there were only five children names on the roster. During the visit, LPAs observed two children wandering near the staircase. LS claimed she incorrectly scheduled children's drop off and pickup time, resulting in an overlap. Additionally, LS claimed she printed several children's records to provide to parents for completion and LS did not furnish or have at least three children's records available for review.

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. The following violation(s) of California Code of Regulations, Title 22, Division 12, were cited during today's visit. Appeal Rights were provided.

(Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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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: 06/01/2023
NARRATIVE
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LPA Melchisedeck Augustin informed licensee, Monisa Sediqi that this report dated 06/01/2023 document(s) two 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, LPA Melchisedeck Augustin informed the licensee to provide a copy of this licensing report dated 06/01/2023 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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/01/2023 02:22 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/01/2023 at 12:30 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
102416.5(a)

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The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by: Based on LPAs' observations and head count of 15 children in care with LS and S1 at
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LS agreed to submit a written statement detailing the positive steps she intends to take to comply with CCR 102416.5(a) and the department will conduct a follow up POC visit to determine compliance with capacity.
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9:51am. This poses/posed an immediate health, safety and/or personal rights risk to the children in care.
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Type A
06/02/2023
Section Cited
CCR102417(g)(3)

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Where children less than five years old are in care, stairs shall be fenced or barricaded.

This requirement was not met as evidenced by: based on LPAs observation of the child safety gate no fully securing the staircase in the living
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Licensee stated she will find a way to barricade the stair case in the living room and a POC visit will be conducted to verify compliance.
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 room. This poses an immediate 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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/01/2023 02:22 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/01/2023 at 12:42 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2023
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 complete facility roster and submit complete roster by 6/15/2023 via mail, email or fax.
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agency upon request.

This requirement was not met as evidenced by: Based on Licensee did not furnish a comple 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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FAX 707-588-5099
Type B
06/15/2023
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 that S1 would obtain the required immunization record and Licensee would submit S1's immunization record to the department by 6/15/2023.
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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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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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/01/2023 02:22 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/01/2023 at 01:34 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2023
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 or have at least three children's records available for review.
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LS stated she will review all children's records and ensure all records are complete and a POC visit will be conducted to verify compliance.

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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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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