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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010798
Report Date: 01/23/2026
Date Signed: 01/23/2026 06:21:26 PM

Document Has Been Signed on 01/23/2026 06:21 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRFIELD PRESCHOOL & CHILDCAREFACILITY NUMBER:
483010798
ADMINISTRATOR/
DIRECTOR:		OLDANI, SABRINAFACILITY TYPE:
860
ADDRESS:1004 UTAH STREETTELEPHONE:
(901) 240-7791
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 44TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
01/23/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Monika VermaTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Amy Strother and Jessica Gaumann made an unannounced visit to the facility for the purpose of conducting a complaint investigation visit. This Case Management visit is added to today’s visit as a result of information obtained during today’s complaint investigation.

Upon arrival, LPAs requested a current roster of children in care at 10:33am from licensee (L1) Monika Verma. LPA Strother questioned if roster was current. L1 stated she did not have a more current roster available. During the visit, L1 worked on updating the roster and was able to provide a completed current roster.

During the investigation of complaint 01-CC_20251106124816, LPAs became aware of a child (C1) exiting the playground and entering the neighbor’s yard with no supervision from staff. L1 did not report the incident to the Department as required.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee, Monika Verma.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809-D. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Jessica Gaumann
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/23/2026 06:21 PM - It Cannot Be Edited


Created By: Jessica Gaumann On 01/23/2026 at 02:55 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: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2026
Section Cited
CCR
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 agency upon request.

This requirement is not met as evidenced by:
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Licensee stated she will submit a written statement detailing the procedure of how she will maintain a current roster for her facility to the Department via email to LPA Strother: amy.strother@dss.ca.gov
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Based on record review the facility roster was incomplete upon request, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/02/2026
Section Cited
CCR101212(d)(1)(C)

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(d)Upon the occurrence, during the operation of the child care center…a report shall be made to the Department by telephone or fax within the Department's next working day… In addition, a written report…shall be submitted to the Department within seven days…(1) Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

This requirement is not met as evidenced by:
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Licensee stated she will submit the unusual incident report for this incident. She will watch the Child Care Center Reporting Requirements Video on CCLD’s website: https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/ and then send to LPA the signatures declaring that the video has been viewed and a written procedure for how reporting will be handled in the future sent to the Department via email to LPA Strother: amy.strother@dss.ca.gov
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Based on interviews, licensee did not report child’s absence to the Department and did not submit a written incident report, which poses a potential health, safety or personal rights risk to persons 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.
Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:
Jessica Gaumann
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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