073404859-1-19-2021-02-CC-SJON-BY4SEQ-20210210124908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073404859
Report Date: 01/19/2021
Date Signed: 01/19/2021 03:11:13 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
11/02/2020 and conducted by Evaluator Monica Mathur

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20201102133043

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: 8	DATE:	01/19/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Nicole Burns		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff left children unsupervised

INVESTIGATION FINDINGS:

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On 01/19/21 at 2:30 PM Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Subsequent Complaint Investigation at Super Kidz Club (School Age program) via telephone call due to COVID 19 restrictions. LPA spoke with Director, Nicole Burns and explained the purpose of today’s investigation. The finding for the above allegation was also delivered during the call.

During the course of investigation the department completed a physical plant inspection, reviewed facility records, reviewed staff records, and conducted interviews. Based on the interviews and information obtained throughout the investigation, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiencies have been cited for this allegation. Exit interview conducted with Director. Report to be signed by Director and returned to CCL no later than end of 01/21/21.

Unsubstantiated

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: 01/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

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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