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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073408270
Report Date: 11/10/2022
Date Signed: 12/02/2022 02:57:35 PM

Substantiated


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
11/10/2022 and conducted by Evaluator Tasha Hackett-Alexander
COMPLAINT CONTROL NUMBER: 02-CC-20221110120850
FACILITY NAME:SUPER KIDZ CLUBFACILITY NUMBER:
073408270
ADMINISTRATOR:BURNS, NICOLEFACILITY TYPE:
830
ADDRESS:2140 MINERT RDTELEPHONE:
(925) 698-8556
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:9CENSUS: 4DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:NICOLE BURNSTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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PERSONAL RIGHTS- Staff member had a day care child in an area not cleared by community care licensing.
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT TO CHANGE THE WORDING OF THE ALLEGATION. NO OTHER CHANGES ARE BEING MADE TO THE REPORT

LICENSING PROGRAM ANALYST TASHA ALEXANDER MET WITH CENTER DIRECTOR NICOLE BURNS IN REGARDS TO THE ABOVE COMPLAINT ALLEGATION.

UPON ARRIVAL THERE ARE 4 INFANTS IN CARE ALONG WITH 1 TEACHER AND 1 AIDE IN THE INFANT ROOM. TODAY INTERVIEWS WERE CONDUCTED WITH INFANT STAFF AND DIRECTOR AND FACILITY ROSTERS WERE REVIEWED.

BASED ON LPAs OBSERVATIONS AND INTERVIEWS WHICH WERE CONDUCTED AND RECORD REVIEWS, THE PREPONDERANCE OF EVIDENCE STANDARD HAS BEEN MET, THEREFORE THE ABOVE ALLEGATION IS FOUND TO BE SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 Chapter 1 are being cited on the attached LIC 9099-D

AN EXIT INTERVIEW WAS CONDUCTED. A NOTICE OF SITE VISIT WAS GIVEN
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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-20221110120850
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: SUPER KIDZ CLUB
FACILITY NUMBER: 073408270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2022
Section Cited
CCR
101223
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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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LICENSEE WILL ENSURE THAT NO STAFF WILL WALK WITH CHILDREN IN THE FRONT OF THE FACILITY NOR SIT WITH DAY CARE CHILDREN IN THEIR PERSONAL VEHICLES. LICENSEE WILL ALSO HAVE STAFF REVIEW PERSONAL RIGHTS VIDEOS. LICENSEE WILL SUBMIT A SUMMARY OF WHAT WAS REVIEWED AND A SIGN IN SHEET OF STAFF THAT ATTENDED BY 11/22/22
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THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY: INVESTIGATION REVEALED A CHILD WAS TAKEN TO A STAFF MEMBER'S VEHICLE IN THE FACILITY PARKING LOT TO SIT WITH THE STAFF MEMBER TO LET AN UPSET CHILD "CALM DOWN". THIS AREA IS NOT LICENSED AS A DAY CARE AREA.
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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.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2