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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073408270
Report Date:
12/02/2022
Date Signed:
12/02/2022 03:22:59 PM
Document Has Been Signed on
12/02/2022 03:22 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 CLUB
FACILITY NUMBER:
073408270
ADMINISTRATOR:
BURNS, NICOLE
FACILITY TYPE:
830
ADDRESS:
2140 MINERT RD
TELEPHONE:
(925) 698-8556
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
9
TOTAL ENROLLED CHILDREN:
9
CENSUS:
6
DATE:
12/02/2022
TYPE OF VISIT:
Case Management - Deficiencies
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
NICOLE BURNS
TIME COMPLETED:
03:30 PM
NARRATIVE
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2:00PM- LICENSING PROGRAM ANALYST TASHA ALEXANDER MET WITH CENTER DIRECTOR NICOLE BURNS TO CLEAR DEFICIENCIES CITED DURING 11/9/22 ANNUAL REQUIRED AND COMPLAINT INSPECTION/INVESTIGATION.
TODAY ALL STAFF HAS IMMUNIZATION RECORDS IN FILE
ALL STAFF HAS UPDATED THE MANDATED REPORTER TRAINING.
STAFF HAS SUBMITTED UP TO DATE HEALTH SCREENING FORMS
THERE ARE UP TO DATE MENUS POSTED AROUND THE FACILITY
STAFF IS NO LONGER "WALKING" THE INFANTS AROUND IN UNCLEARED (BY COMMUNITY CARE LICENSING) AREAS OF THE FACILITY
ALL DEFICIENCIES ARE CLEARED AS OF TODAY.
THERE ARE NO DEFICIENCIES CITED TODAY.
A NOTICE OF SITE VISIT WAS GIVEN AND POSTED.
SUPERVISORS NAME
:
Loretta Dyson
LICENSING EVALUATOR NAME
:
Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/02/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/02/2022
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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