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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010089
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:46:55 PM

Document Has Been Signed on 10/14/2021 03:46 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SEDIQI, MONISA FCCHFACILITY NUMBER:
483010089
ADMINISTRATOR:SEDIQI, MONISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 718-3744
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
10/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Monisa Sediqi, Roheena SediqiTIME COMPLETED:
02:30 PM
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A case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Yang at the request of the licensee to inspect and approve a previously designated off-limits room in the home for child care use. The licensee requested approval to use the converted garage for child care. During today's visit, the LPA met with the licensee and the licensee's assistant, Roheena Sediqi. The room is labeled as "Garage" on the floor sketch submitted by the licensee. The facility sketch shall be updated to reflect the addition of the new on limits child care room. An updated fire clearance was obtained on 10/12/2021. The garage is now approved for childcare use.

There were no Title 22 deficiencies observed during today's inspection.
Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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