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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408281
Report Date: 11/05/2019
Date Signed: 11/07/2019 01:28:04 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: 24DATE:
11/05/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Fey SaeteurnTIME COMPLETED:
12:15 PM
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LPA Susan Neeson made an unannounced Case Management site inspection visit. the visit began at 8:15 AM. Met with Fey Saeteurn, new Director.

The purpose of the visit is to determine if deficiencies cited on 8/27/19 have been corrected. Today the sign-in and out sheets were examined and all are correct. There is sufficient resilient material under all climbing structures and 3 staff, including the new Director, have the 16-hour Health and Safety certification.

All three deficiencies are corrected.

An exit interview was given.

TYPED REPORT WAS NOT ISSUED DURING SITE VISIT DUE TO MECHANICAL MALFUNCTION.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
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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