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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073405652
Report Date: 01/20/2022
Date Signed: 01/20/2022 11:30:57 AM

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
11/09/2021 and conducted by Evaluator Catherine Fernandes
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20211109165101
FACILITY NAME:SUPER KIDZ CLUBFACILITY NUMBER:
073405652
ADMINISTRATOR:BURNS, NICOLEFACILITY TYPE:
850
ADDRESS:2140 MINERT RD.TELEPHONE:
(925) 682-0143
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:15CENSUS: 20DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Nicole BurnsTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Child sustained an unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/20/2022 at 11:14AM, Licensing Program Analyst (LPA) Catherine Fernandes arrived to the center to deliver the findings to the above allegation. LPA met with Director Nicole Burns. There are three components at the center. During the visit there were five staff members, four infants and 20 preschoolers in care. During the course of the investigation LPA Fernandes reviewed center files, conducted interviews with staff and a random sampling of families as well as observe the center.
The above allegations states that a child sustained injuries while in care however it was undetermined whether or not the child was injured while in care. Parent interviews indicated conflicting information regarding injuries while in care and during staff interviews it was determined that staff was unaware that the child involved had any injuries. Therefore the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted
Report and Appeal Rights and Notice of site visit provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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