073404859-9-30-2020-02-CC-SJON-BUKLCJ-20201020083826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073404859
Report Date: 09/30/2020
Date Signed: 09/30/2020 04:12:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2020 and conducted by Evaluator Monica Mathur

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200715162517

FACILITY NAME:	SUPER KIDZ CLUB		FACILITY NUMBER:	073404859
ADMINISTRATOR:	NICOLE BURNS		FACILITY TYPE:	840
ADDRESS:	2140 MINERT ROAD		TELEPHONE:	(925) 682-0143
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	30	CENSUS: 10	DATE:	09/30/2020
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Nicole Burns		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff left children unsupervised while in care

INVESTIGATION FINDINGS:

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On 09/30/20 at 11:45 AM Licensing Program Analysts (LPAs) Monica Mathur and Jaylena Miller conducted an Unannounced Subsequent Complaint Investigation at Super Kidz Club. LPAs met with Director, Nicole Burns and explained the purpose of today’s investigation. LPAs conducted interviews and a facility inspection. Finding for the above allegation was delivered.

Complainant alleges that staff left children unsupervised while in care.
During the course of the investigation, LPA inspected the facility, reviewed records, and conducted interviews. Director states she is the only opening staff person at morning drop off time to check children in. Children which include infant, preschool age and school age are seated at a table in the Main Room while Director has to leave the area and step outside the front entrance to check in next arriving child.

Based on information obtained, it is concluded Director is unable to have complete physical and visual supervision when she is outside the front door. Due to absence of supervsion, it poses an immediate risk to the health and safety of children in care. Type A deficiency is cited and immediate civil penalty of $500 assessed on page 9099-D.

CONTINUED ON NEXT PAGE 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 02-CC-20200715162517

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUPER KIDZ CLUB	FACILITY NUMBER: 073404859
	VISIT DATE: 09/30/2020

NARRATIVE

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Based on the interviews and information obtained throughout the investigation, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 is being cited on 9099-D page. Exit interview was conducted, where this report, the deficiency, plan of correction, and appeal rights were discussed with Nicole Burns.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be posted in the facility and given to each existing parent by the end of today or next day child is in care. Report also has to be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 02-CC-20200715162517

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUPER KIDZ CLUB	FACILITY NUMBER: 073404859
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/01/2020 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229 Responsibility for Providing Care & Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs (1) No child(ren) shall be left without the supervision of a teacher at any time [...] Supervision shall include visual observation. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By 10/01/20 Director agreed to submit a written plan to CCL on how she will ensure complete supervision of children in care at all times.
	8 9 10 11 12 13 14	Per LPAs investigation and observations, Director did not have complete physical and visual supervision of children as she stepped out of the front door to check in arriving children. This poses an immediate risk to the health and safety of children in care. Immediate Civil penalty of $500 assessed.	8 9 10 11 12 13 14	Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be posted in the facility and given to each existing parent by the end of today or next day child is in care. Report also has to be provided to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file. A civil penalty of $ 500 was assessed and issued during today’s inspection.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sherelle Johnson	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

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