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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408270
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:47:52 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:
073408270
ADMINISTRATOR:BURNS, NICOLEFACILITY TYPE:
830
ADDRESS:2140 MINERT RDTELEPHONE:
(925) 698-8556
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 9TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
07/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nicole BurnsTIME COMPLETED:
01:50 PM
NARRATIVE
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On 7/14/22 Licensing Program Analysts (LPAs) Michelle Sutton and Monica Mathur 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 on 6/29/22 three (3) staff working in the infant center were observed to not have criminal record association to the license. At the time, Director stated she has sent transfer request to Licensing when staff were employed over a period of 1-2 years. However director failed to provide proof of fax sent. Director admits she is aware of Guardian system but does not use it. LPAs decided to defer taking action in order to verify if any submissions were received. Licensing office confirmed no submissions were received as of 6/29/22.

Director Nicole Burns faxed to Licensing pictures of transfer request forms, without filling out the correct form and filling out all details. After several attempts by Licensing office requesting to provide complete, clear and detailed information. The facility still has not provided the required information that is readable and clear.

During today's inspection LPAs conducted staff and facility file reviews. LPAs checked for three staff's clearances on LIS and Guardian. One staff is associated, eligible to provide care for children and two staff still need to be associated to the facility.

A citation issued today for criminal record clearance for Gloria Setchell with a civil penalty of $500 ($100 per person per day for a maximum 5 days). Gloria Setchell needs additional steps in her clearance process. LPAs observed Gloria present during today's inspection.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 01:47 PM - It Cannot Be Edited


Created By: Michelle Sutton 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: 073408270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
101170(e)(3)

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101170 Criminal Record Clearance(e) All individuals subject to a criminal record [..]prior to working [..] licensed facility:(3) Request and be approved for a transfer of a criminal record exemption[...] This requirement is not met as evidenced by:
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By 7/15/22 Director agreed to to mail Oakland Regional Office complete Transfer Request forms, copy of driver license and follow up with the office to check for clearance.
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Based on observation record reviews, the facility failed to provide complete transfer request forms for staff gloria Setechell. This is an immediate 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: 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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Document Has Been Signed on 07/14/2022 01:47 PM - It Cannot Be Edited


Created By: Michelle Sutton On 07/14/2022 at 12:38 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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record [..]prior to working [..] 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 7/21/22 Director agreed to to mail Oakland Regional Office complete Transfer Request forms, copy of driver license and follow up with the office to check for clearance.
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Based on observation record reviews, the facility failed to provide complete transfer request forms for staff Nicole Kuntz. 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: 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


LIC809 (FAS) - (06/04)
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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: 073408270
VISIT DATE: 07/14/2022
NARRATIVE
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Due to the issuance of Type A, this report has to be provided to all parents of currently and future enrolled over next 12 months. Report and deficiency page also to be posted in public view. A copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports to be signed by parent and kept in child file.

The following deficiencies were 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 the licensee Nicole Burns.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
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
LIC809 (FAS) - (06/04)
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