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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073404859
Report Date: 06/28/2023
Date Signed: 06/28/2023 02:43:11 PM

Unsubstantiated


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
04/03/2023 and conducted by Evaluator Tasha Hackett-Alexander
COMPLAINT CONTROL NUMBER: 02-CC-20230403155723
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: 11DATE:
06/28/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:NICOLE BURNSTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
PERSONAL RIGHTS- Staff yells at day care child

PERSONAL RIGHTS- Staff handle day care child in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LICENSING PROGRAM TASHA ALEXANDER MET TODAY WITH CENTER DIRECTOR NICOLE BURNS TO DELIVER THE FINDINGS TO THE ABOVE COMPLAINT FINDINGS.

UPON ARRIVAL THERE ARE 11 SCHOOL AGE CHILDREN PRESENT ALONG WITH 3 SCHOOL AGE STAFF. THE DIRECTOR IS INCLUDED IN TODAY'S RATIO. DURING THIS ANALYST'S LAST VISIT INTERVIEWS WERE CONDUCTED WITH STAFF AND A COPY OF THE FACILITY ROSTER WAS RECEIVED. TODAY INTERVIEWS WERE CONCLUDED.

ALTHOUGH THE ALLEGATION MAY HAVE HAPPENED OR IS VALID, THERE IS NOT A PREPONDERANCE OF EVIDENCE TO PROVE THE ALLEGED VIOLATIONS DID OR DID NOT OCCUR, THEREFORE THE ALLEGATIONS ARE UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
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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