434414291-6-3-2019-07-CC-ASTR-BD4RAH-20190613125109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434414291
Report Date: 06/03/2019
Date Signed: 06/03/2019 04:19:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2019 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20190508103127

FACILITY NAME:	THUNDERBULL, KIMBERLY		FACILITY NUMBER:	434414291
ADMINISTRATOR:	THUNDERBULL, KIMBERLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 663-0237
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 8	DATE:	06/03/2019
		UNANNOUNCED	TIME BEGAN:	02:54 PM
MET WITH:	Kimberly Thunderbull		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Licensee does not provide a safe environment for day care children

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced subsequent complaint investigation. Upon arrival of inspection, Assistant Andrea Leon and 4 preschool children were present. Licensee Kimberly Thunderbull and 4 school-age children arrived at 3:04PM. LPA explained the reason for the inspection to Licensee.

During the course of the investigation, LPA inspected the physical plant. LPA also interviewed Licensee, Assistant, and 3 children. Licensee stated that there was an incident where her dog nipped a child's finger. LPA observed a picture of the child's finger following the incident. Licensee stated that her dog is either in the formal living room or upstairs. Licensee stated that she uses the formal living room for naptime and then will move her

----continues on 9099 dated 06/03/2019 page 2----

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20190508103127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/10/2019 Section Cited CCR 102424(a)(3)	1 2 3 4 5 6 7	Personal Rights. Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 06/10/2019, Licensee will submit a written plan outlining on how she provide a safe environment in the future.
	8 9 10 11 12 13 14	Based on interviews, Licensee failed to provide safe accommodations to children in care. Licensee's dog nipped a child's finger. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20190508103127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/03/2019

NARRATIVE

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dog upstairs, which is off-limits. LPA observed there are two gates to barricade the off-limit areas; one is placed by the kitchen and the second one is placed right before the stairs. During the investigation, LPA observed that her dog was in the off-limit areas. Based on the information obtained throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

As a result of this complaint investigation, a Type B deficiency has been cited. An exit interview was conducted where this report, the citation, plan of correction, and appeals rights were discussed and provided with Licensee.

A notice of site visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019

LIC9099 (FAS) - (06/04)

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