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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405652
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:27:43 PM

Document Has Been Signed on 06/29/2022 03:27 PM - It Cannot Be Edited

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:SUPER KIDZ CLUBFACILITY NUMBER:
073405652
ADMINISTRATOR:BURNS, NICOLEFACILITY TYPE:
850
ADDRESS:2140 MINERT RD.TELEPHONE:
(925) 682-0143
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: DATE:
06/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nicole BurnsTIME COMPLETED:
03:30 PM
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On 6/29/22 at 2 pm Licensing Program Analysts (LPAs) Monica Mathur and Michelle Sutton conducted a Case Management inspection at Super Kidz Club Inc. and met with Licensee/Director, Nicole Burns. During today's inspection numerous staff were not associated to the facility. When files and records were requested, Director Nicole Burns had to leave for an urgent appointment and did not have all files/records for fingerprint associations/ transfer requests available in the facility today. Further investigation is needed to verify if staff are cleared and associated to the license.

This report was reviewed and discussed with Assistant Director, Marshay Horne. NOTICE OF SITE VISIT WAS ISSUED, MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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