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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414291
Report Date: 05/17/2019
Date Signed: 05/17/2019 11:30:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:THUNDERBULL, KIMBERLYFACILITY NUMBER:
434414291
ADMINISTRATOR:THUNDERBULL, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 663-0237
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 8DATE:
05/17/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Kimberly ThunderbullTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced case management-deficiencies. LPA met with Licensee Kimberly Thunderbull and explained the reason for the investigation.

Upon arrival of inspection, LPA observed that Assistant was alone with seven children. Licensee was currently out running errands. LPA also observed that Licensee's adult son was present upon arrival of inspection. Licensee stated that her adult son does not help with the day care children. Licensee arrived shortly after. LPA discussed and provided Licensee with the family child care capacity and ratio. Licensee understands that if there is no qualified assistant, the capacity reverts back to the requirement for a Small Family Child Care. Licensee also understands that her seventh and eighth child needs to be at least 6 years and one needs to be enrolled in kindergarten.

As a result of today's inspection, a Type A deficiency has been cited. An exit interview was conducted with Licensee Kimberly Thunderbull, where this report, the citation, plan of correction, appeal rights, were discussed and provided to Licensee

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 05/17/2019 and obtain a signed copy LIC 9224 for each child in care within one business days. LPA also discussed with Licensee that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA provided a copy of LIC 9224 and fact sheet to Licensee.

A Notice of Site Visit was issued and must be posted for 30 consecutive days; along with a copy of 809 report.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: THUNDERBULL, KIMBERLY
FACILITY NUMBER: 434414291
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2019
Section Cited
CCR
102416.5(g)
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Staffing Ratio and Capacity. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This requirement is not met as evident by:
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By POC 05/18/2019, Licensee stated that she will submit a written plan outlining how she wil ensure that there is at least two assistant present if she needs to pick up children or run errands. Licensee
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Based on observation and interview, LPA observed seven day care children, whom none were school age with the Assistant. This poses an immediate risk to the health and safety to the children in care.
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stated that she will submit written plan to Licensing office.
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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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
LIC809 (FAS) - (06/04)
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