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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073408281
Report Date: 11/05/2019
Date Signed: 11/07/2019 02:23:54 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
08/21/2019 and conducted by Evaluator Susan Neeson
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20190821161924
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
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Fey SaeteurrnTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff disciplines child in care for an extended amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Susan Neeson met with Fey Saeteurn, Director, regarding the above allegation for a complaint investigation. Visit began at 8:15 AM. There are 24 children present, 7 in the toddler option classroom and 17 preschoolers. Interviews have been conducted.. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, 101223a3 is being cited on the attached LIC 9099 D.

The attached type B deficiencies are cited today and must be corrected by the due date.

Appeal Rights were discussed.

An exit interview was given.

TYPED REPORT WAS NOT ISSUED DURING VISIT DUE TO MECHANICAL MALFUNCTION.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 02-CC-20190821161924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2019
Section Cited
CCR
101223a3
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Personal Rights (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or
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Fey Saeteurn states that this has ceased and training has been given all staff. A plan and procedure for discipline that respects children's personal rights will be submitted by 11/12/19.

Failure to correct may result in civil penalties,
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toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This was not met in that there were credible reports of excessive time out being given some children.
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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: 11/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2