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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405652
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:47:56 PM

Document Has Been Signed on 07/14/2022 01:47 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: 23DATE:
07/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nicole BurnsTIME COMPLETED:
02:00 PM
NARRATIVE
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On 7/14/22 at 11:30 am Licensing Program Analysts (LPAs) Monica Mathur and Michelle Sutton conducted an unannounced Case Management inspection at Super Kidz Club and met with Director/Licensee, Nicole Burns. LPAs explained the purpose of today's inspection.

During inspection of 6/29/22 five (5) staff, of which 4 are currently working and 1 is now ex-staff- were observed to not have criminal record association to the license. Director stated she sent transfer requests to Licensing as and when they were employed over a period of 1-2 years; however failed to provide proof of fax requests sent. Director admits she is aware of Guardian system but does not use it. LPAs decided to defer taking any action during the inspection until they could verify if any submissions were received. Licensing office confirmed no submissions were received for as of 6/29/22.

On 7/1/22 Director, Nicole faxed photos of transfer request forms which were incomplete, information cut out, without full details. After multiple attempts by Licensing office requesting to provide complete, clear, detailed information, facility still has not provided the required information that is readable and clear. Staff could not be associated to the license due to insufficient and illegible information.

During today's inspection, LPA checked for 5 staff's clearances on LIS and Guardian. ALL 5 STAFF HAVE ELIGIBLE CLEARANCES BUT ARE STILL NOT ASSOCIATED TO THE LICENSE. 2 staff are associated to their previously employed child care facilities, while other 3 staff have eligible clearance but are not associated anywhere else. During today's inspection, LPA observed 4 staff who currently work here and are present today.

continued on 809C
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SUPER KIDZ CLUB
FACILITY NUMBER: 073405652
VISIT DATE: 07/14/2022
NARRATIVE
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 On 6/29/22 during exit interview, LPAs had discussed facility responsibility to confirm that staff has been associated before presence at the facility and Director has not done that which is evident with those 4 staff still being present here today.

Facility is cited Type B since staff have eligible clearances but facility failed to comply with Criminal Record Clearance associations requirement which poses a potential risk to health and safety of children. Citation issued on 809D page. This report was discussed with Director/Licensee, Nicole Burns.

NOTICE OF SITE VISIT ISSUED, MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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Document Has Been Signed on 07/14/2022 01:47 PM - It Cannot Be Edited


Created By: Monica Mathur On 07/14/2022 at 12:15 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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
101170(e)(2)

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101170 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility (2) Request a transfer of a criminal record clearance as specified in Section 101170(f). This requirement is not met as evidenced by:
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By 7/15/22 Director agreed to mail to Oakland Regional Office, clear, complete Transfer Request forms with copy of drivers license; and follow up to check when they get associated.
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Per record review, facility failed to provide complete transfer request forms for 5 staff who have eligible clearance, are present in the facility but not associated. This poses a potential risk to safety of childtren.
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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


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