434414291-3-25-2021-07-CC-MSMS-BZFSWX-20210325141504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414291
Report Date: 03/25/2021
Date Signed: 03/25/2021 02:16:14 PM

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, 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: 5	DATE:	03/25/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kimberly Thunderbull		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management tele-inspection (via FaceTime) and spoke with Kimberly Thunderbull, Licensee. The Licensee has __ children in care today. Licensing Program Analyst (LPA) became aware that the Licensee’s youngest son, Evan Thunderbull, who resides in the home, turned 18 years of age on March 23, 2020, and did not obtain his criminal record and child abuse index clearances until November 6, 2020. LPA Matos verified the Department Licensing Information System (LIS) on November 6, 2020 and confirmed that Evan Thunderbull had obtained the Department of Justice (DOJ) and Federal Bureau of Investigation (FBI) clearances on November 5, 2020 and the Child Abuse Child Index (CACI) clearance on November 6, 2020. Alondra Mariposa Silva, Evan Thunderbull’s child’s mother, resided in the home from July 2020 to January 5, 2021 without criminal record and child abuse index clearances. LPA reminded the Licensee several times about Alondra’s requirement to get fingerprinted. The Licensee advised LPA Matos on January 6, 2021 that Alondra moved out of the home on January 5, 2021 to take care of a family member. Report continued on the following page (809-C):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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
	VISIT DATE: 03/25/2021

NARRATIVE

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Continuation of previous page (LIC 809):

A “Type A” deficiency is being cited based on interviews conducted and record reviews in accordance with the California Code of Regulations, Title 22 (see LIC 809-D). Civil penalties are also being assessed as a result of the "Type A" deficiency cited today (see LIC 421B).

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Licensee. A copy of this report and appeal rights was discussed with the Licensee. LPA to forward a copy of today’s report to Kimberly Thunderbull, Licensee, via email (kjennings71@gmail.com). LPA requested that Kimberly Thunderbull, Licensee, respond to the “read receipt” confirmation/send confirmation of receipt email to LPA within 24 hours confirming receipt of today’s report.

A Notice of Site Visit will also be forwarded to Kimberly Thunderbull, Licensee, via email and will be required to be posted near the entrance to the day care along with today’s report for 30 days. LPA advised the Licensee that she must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility for the next 12 months per the AB633 reporting requirements.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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: 03/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2021 Section Cited	1 2 3 4 5 6 7	Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Evan Thunderbull, resident of the home, turned 18 years of age on 03/23/20 and did not obtain his criminal record and child index clearances until 11/06/20. Alondra Mariposa Silva, former adult resident, moved into the home in July 2020 and resided in the home until 01/05/21. Alondra did not obtain her criminal record and child abuse index clearances while residing in the home.	8 9 10 11 12 13 14	Civil penalties of $1,000 (max of $500 per person) assessed today (see LIC 421B). The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months per the AB633 requirements.
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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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC809 (FAS) - (06/04)

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