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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073404859
Report Date: 11/09/2022
Date Signed: 11/14/2022 06:28:02 PM


Document Has Been Signed on 11/14/2022 06:28 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:SUPER KIDZ CLUBFACILITY NUMBER:
073404859
ADMINISTRATOR:NICOLE BURNSFACILITY TYPE:
840
ADDRESS:2140 MINERT ROADTELEPHONE:
(925) 682-0143
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:30CENSUS: 0DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:NICOLE BURNSTIME COMPLETED:
04:30 PM
NARRATIVE
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LICENSING PROGRAM ANALYST TASHA ALEXANDER MET TODAY WITH CENTER DIRECTOR NICOLE BURNS FOR AN UNANNOUNCED 1 YEAR/REQUIRED INSPECTION. TODAY UPON ARRIVAL, ALL SCHOOL AGE CHILDREN ARE CURRENTLY AT SCHOOL. THE FACILITY HAS AGE APPROPRIATE FURNITURE WHICH APPEARS TO BE IN GOOD REPAIR. THE INDOOR AND OUTDOOR ACTIVITY SPACE APPEARED TO BE IN GOOD REPAIR. DISINFECTANTS, CLEANING SOLUTIONS, POISONS AND OTHER ITEMS THAT ARE DANGEROUS TO CHILDREN WERE INACCESSIBLE DURING TODAY'S INSPECTION. THE SINKS WERE OBSERVED TO BE IN OPERABLE CONDITION. THE FLOORS ARE FREE OF TRIPPING HAZARDS. FACILITY PROVIDES SNACKS. THE STORAGE AREA WAS OBSERVED TO BE CLEAN AND FREE OF EVIDENCE OF RODENTS. SNACKS ARE PROTECTED AGAINST CONTAMINATION. ALL STORAGE CONTAINERS FOR SOLID WASTE HAVE TIGHT FITTING LIDS THAT ARE IN GOOD REPAIR. DRINKING WATER IS AVAILABLE BOTH INDOORS AND OUTDOORS. THERE ARE NO MENUS POSTED TODAY. OUTDOOR ACTIVITY SPACE AND PLAYGROUND EQUIPMENT WAS OBSERVED TO BE SAFE AND FREE OF HAZARDS WITH APPROPRIATE MATERIAL TO ABSORB FALLS. THERE ARE COVERED SEATING AREAS ON THE PLAYGROUND TO PROVIDE SHADE FOR CHILDREN.

THE FACILITY IS OPERATING WITHIN IT'S LICENSED CAPACITY. THE FACILITY IS WITHIN RATIO TODAY. LPA DID NOT OBSERVE ANY CHILD LEFT WITHOUT SUPERVISION DURING INSPECTION. LPA VERIFIED THAT THERE IS AT LEAST ONE STAFF MEMBER ON THE PREMISES THAT HAS CURRENT CPR/1ST AID TRAINING CARDS. A PHYSICAL CENSUS WAS TAKEN OF ALL CHILDREN PRESENT AND CROSSED REFERENCED WITH THE SIGN/OUT SHEETS.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SUPER KIDZ CLUB
FACILITY NUMBER: 073404859
VISIT DATE: 11/09/2022
NARRATIVE
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A SAMPLE OF CHILDREN'S RECORDS WERE REVIEWED. FILES REVIEWED CONTAINED EMERGENCY INFORMATION. TEACHERS PRESENT TODAY MEET QUALIFICATION REQUIREMENTS.

Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SUPER KIDZ CLUB
FACILITY NUMBER: 073404859
VISIT DATE: 11/09/2022
NARRATIVE
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at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

PLEASE SEE 809-D FOR CITATION.



An exit interview was conducted. A notice of site visit was posted.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/14/2022 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY: A REVIEW OF STAFF RECORDS REVEALED TEACHER AIDE ESSENCE MIMS DOES NOT HAVE IMMUNIZATION RECORDS IN FILE
POC Due Date: 11/24/2022
Plan of Correction
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LICENSEE WILL HAVE TEACHER AIDE ESSENCE BROOKS OBTAIN HER IMMUNIZATION RECORDS AND SUBMIT A COPY TO COMMUNITY CARE LICENSING BY 11/24/22. RECORDS MUST SHOW PROOF OF MMR, PERTUSSIS AND FLU (OR DECLARATION) VACCINE.
Type B
Section Cited
HSC
1596.8662(c)
Administration of Child Day Care Licensing
(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY : TEACHER AIDE DONTASHIA BROOKS' MANDATED REPORTER CERTIFICATE EXPIRED ON 12/19/21
POC Due Date: 11/24/2022
Plan of Correction
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LICENSEE WILL HAVE TEACHER AIDE DONTASHIA BROOKS UPDATE HER MANDATED REPORTER TRAINING AND SUBMIT A COPY OF THE UPDATED CERTIFICATE TO COMMUNITY CARE LICENSING BY 11/4/22

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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 11/14/2022 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY: A REVIEW OF STAFF RECORDS REVEALED TEACHER AIDE ESSENCE MIMS DOES NOT HAVE A COMPLETED HEALTH SCREENING FORM IN FILE.
POC Due Date: 11/24/2022
Plan of Correction
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LICENSEE WILL HAVE TEACHER AIDE ESSENCE OBTAIN A COMPLETED HEALTH SCREENING FORM FROM HER PHYSICIAN AND SUBMIT A COPY TO COMMUNITY CARE LICENSING BY 11/24/22
Type B
Section Cited
CCR
101227(a)(6)
Food Service
(a) In child care centers providing meals to children, the following shall apply: (6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY: DURING THE INSPECTION OF THE FACILITY, THERE ARE NO MENUS POSTED AT THE FACILITY.
POC Due Date: 11/17/2022
Plan of Correction
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LICENSEE WILL ENSURE THAT MENUS ARE POSTED AT LEAST ONE WEEK IN ADVANCE IN AN AREA FOR REVIEW BY PARENTS. LICENSEE WILL CREATE A MENU (SNACKS) TO BE POSTED AT THE FACILITY AND SUBMIT A COPY ALONG WITH A STATEMENT OF WHERE THE MENUS WILL BE POSTED TO COMMUNITY CARE LICENSING BY 11/17/22

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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5