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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408281
Report Date: 08/27/2019
Date Signed: 08/27/2019 04:36:56 PM

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:SUPREME KIDS ACADEMYFACILITY NUMBER:
073408281
ADMINISTRATOR:RIVERA, NADIHEZKAFACILITY TYPE:
850
ADDRESS:3065 RICHMOND PARKWAYTELEPHONE:
(510) 224-7377
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:48CENSUS: 26DATE:
08/27/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Brooke Gibbons, Tera Taylor and Antea GregoryTIME COMPLETED:
05:00 PM
NARRATIVE
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An unannounced Annual/Random site inspection visit was conducted by LPA Susan Neeson.LPA met with ap Tera Taylor and Antea Gregory, Board Members. Visit began at 12:15 PM. A health and safety inspection was conducted. There are 9 toddler option children and 17 preschool children present.

The preschool and toddler rooms are minimally equipped with age appropriate materials and equipment.children. The office is be used as the isolation area for sick children while waiting for parents to pick them up. Cots and mats for napping are available. According to Tera Taylor, no children currently have need of temporay medication.

The play yard is fenced in all around. Trees sufficient shade in the play yard. Water is available inside and for outside, water pitcher and cups will be brought out during outdoor activities. The center provides lunch, am/pm snacks. The kitchen is not accessible to children in care. First aid supplies are available in the center.

Licensee is reminded that ALL assistants, volunteers or adults that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.ca.gov

Incidental Medical Services were discussed. No child present is in need of Incidental Medical Services. A plan of operation will be submitted if, in the future, any child requires it.

The following documents were issued: Safe Sleep Regulation Concepts, AB1207 training, safe and healthy diapering, fire and earthquake drills, Car seat information, Department Quarterly update, blue form, Licensee Rights and flu prevention tips.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SUPREME KIDS ACADEMY
FACILITY NUMBER: 073408281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2019
Section Cited

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Outdoor Activity Space(e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. Thiw requirement was not met in that all three climbing structures lack resilient material and are not anchored.

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Type B
09/27/2019
Section Cited

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Director Qualifications and Duties (m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866. This was not met in that no staff member has the full 16-hour certification.
Type B
08/28/2019
Section Cited

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Sign In and Sign Out (a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall have a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (a) in addtion to the sign-in procedure requirement of (1)


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The person who signs the child in/out shall use his/her full legal signature and shall record the time of day. (b) The person who removes the child from, the center shall sign the child in/out. This was not met in that a review of the records revealed 10 children not signed in or out during the last week.
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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.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: SUPREME KIDS ACADEMY
FACILITY NUMBER: 073408281
VISIT DATE: 08/27/2019
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There is a working telephone on site. There is a carbon monoxide detector, smoke detector available and there are fire extinguishers all throughout the center.

Deficiencies are cited on LIC 809 D

Appeal Rights were discussed.

An exit interview was given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3