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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434414291
Report Date: 05/08/2024
Date Signed: 05/08/2024 10:26:08 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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
05/03/2024 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 07-CC-20240503084945
FACILITY NAME:THUNDERBULL, KIMBERLYFACILITY NUMBER:
434414291
ADMINISTRATOR:THUNDERBULL, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 663-0237
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 6DATE:
05/08/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Thunderbull, KimberlyTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee is operating out of ratio.
INVESTIGATION FINDINGS:
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On 5/8/24, at 9:05 AM, Licensing Program Analyst (LPA) Doni Fici and Licensing Program Manager (LPM) Gladys Kuizon arrived unannounced to conduct an initial 10-day complaint investigation visit. LPA and LPM was greeted by Licensee, Thunderbull, Kimberly and explained the purpose of today’s visit. LPA and LPM observed two (2) staff and six (6) children (C1-C6) present during visit.

During visit, LPA and LPM interviewed Licensee. LPA and LPM requested and obtained the following document: Current children’s roster, and 6 children’s files. It was alleged that; Licensee is operating out of ratio. Based on interview conducted with Licensee, LPA and LPM confirmed with Licensee that she was out of ratio a week before because her assistant called out sick and that the Licensee was alone with seven (7) children.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted with Licensee, and a copy of this report reviewed and provided along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 07-CC-20240503084945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: THUNDERBULL, KIMBERLY
FACILITY NUMBER: 434414291
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
102416.5(e)
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102416.5 (e) Staffing ratio and Capacity: (e) 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...
This requirement is not met as evidenced by:
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Licensee will submit a written plan of action to CCL by POC due date by 5PM.
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Based on interview with Licensee, the licensee did not comply with the section cited above by having seven (7) children in care with no assistant, which poses a immediate health, safety or personal rights risk to persons in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC9099 (FAS) - (06/04)
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