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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073408270
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:30:53 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
06/22/2022 and conducted by Evaluator Michelle Sutton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220622095435

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: 8DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nicole BurnsTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not following proper sleeping practices for infants
INVESTIGATION FINDINGS:
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On 6/29/22 at 9:15AM Licensing Program Analysts (LPAs) Michelle Sutton and Monica Mathur conducted a Complaint Investigation at Super Kidz Club and met with director Nicole Burns. Complaint allegation is that Staff are not following proper sleeping practices for infants. During the course of the investigation, LPA inspected the facility, reviewed records, and conducted interviews. It was determine that infants are being swaddled regularly during nap time. Based on the observations and interviews which were obtained throughout the investigation, the preponderance of evidence standard has been met, therefore, the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 is being cited on 9099-D page.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 02-CC-20220622095435
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
VISIT DATE: 06/29/2022
NARRATIVE
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Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be POSTED in the facility and PROVIDED to each existing parent by the end of today or next day child is in care. Report also must be PROVIDED to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each
parent and kept in each child's file.

The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with director Nicole Burns.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 02-CC-20220622095435
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: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited
CCR
101430(a)(3)(C)
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Infant Care Activities 101430 (a) [..]the following shall apply: (3) All infants shall be given the opportunity to sleep without distraction[..] (C) An infant shall not be swaddled while in care. This requirement is not met as evidenced by:
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Director agreed to submit a written statement understanding Infant Safe Sleep Regulations.
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Based on observation, interviews and record reviews that infants are being swaddled regularly during nap time. This is an immediate risk to Health and Safety or Personal Rights risk to persons in care.
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Director will conduct a staff meeting and submit an agenda with attendees signature for Infant Safe Sleep Regulations training.
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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: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4