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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408270
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:36:36 PM

Document Has Been Signed on 06/29/2022 03:36 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:
073408270
ADMINISTRATOR:BURNS, NICOLEFACILITY TYPE:
830
ADDRESS:2140 MINERT RDTELEPHONE:
(925) 698-8556
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 9TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
06/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nicole BurnTIME COMPLETED:
03:35 PM
NARRATIVE
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On 6/29/22 at 9:15 AM Licensing Program Analysts (LPAs) Michelle Sutton and Monica Mathur conducted an unannounced case management inspection.

During the course of a complaint investigation it was discovered that 3 staff at the facility who are caring for children do not have fingerprint clearance and associated to the facility. LPAs have determined there needs to be a further investigation to determine if staff are associated to the facility. During today's visit director had to leave for an urgent appointment and records were not at the facility.

During the course of the complaint investigation it was discover that infants are napping with blankets in the crib.


The following deficiencies was observed (See LIC 809-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 Marshay Horne.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2022 03:36 PM - It Cannot Be Edited


Created By: Michelle Sutton On 06/29/2022 at 02:11 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: 073408270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
101439.1(f)

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101439.1 Infant Care Center Sleeping Equipment (f) Cribs shall be free from all loose articles and objects, including blankets and pillows. This requirement is not met as evidenced by:
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Director agreed to write an written statement understanding the Infant Safe Sleep Regulations.
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Based on observation, interviews and record reviews infants are napping with blankets in the crib.
This is a potential risk to Health and Safety or Personal Rights risk to persons 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: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


LIC809 (FAS) - (06/04)
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