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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405652
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:02:17 PM

Document Has Been Signed on 11/17/2021 01:02 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: 24DATE:
11/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Nicole BurnsTIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/17/21 at 10:45AM, Licensing Program Analyst (LPA) Catherine Fernandes arrived unannounced on another matter and met with Director Nicole Burns. There are 24 preschoolers in care upon arrival and four staff members.

While at the center at 11:05AM, LPA Fernandes reviewed the sign in and sign out sheets and observed missing dates, check in and out times and parent signatures. Director confirmed that sometimes parents do not fill out the form.

At 11:16AM, LPA Fernandes asked Director Nicole if there are any incident or injury reports that happened to child 1 while in care and she confirmed that the center does not keep copies of any incident or ouch reports and that they are only given to child's parents.



The attached type B deficiencies are being cited on the 809D and must be corrected by the due dates.


Exit interview conducted
Report and Appeal Rights provided
Notice of Site visit must be posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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Document Has Been Signed on 11/17/2021 01:02 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 11/17/2021 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUPER KIDZ CLUB
FACILITY NUMBER: 073405652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
CCR
101229.1(a)

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Sign In and Sign Out- In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: a through d. This requirement has not been met as evidence by:
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The Director shall review the Sign in and sign out policies then come up with a plan to ensure the sign in and out sheets are completed.
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Based on center's review of the incomplete sign in and out sheets, which can pose a potential risk to children in care.
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Type B
12/01/2021
Section Cited
CCR101226.3(b)

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Observation of the Child: Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record. This requirement has not been met as evidenced by:
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Center will come up with a way to ensure all injuries, unusual behaviors and signs of illness is not only reported to parents that there is a copy kept in the children's files.
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Based on conformation from the Director and record's review no copies were placed in the children's folders, which can pose a potential risk to children in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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