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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414291
Report Date: 03/18/2024
Date Signed: 03/18/2024 12:14:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/18/2024 12:14 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
SAN JOSE CC RO, 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: 0DATE:
03/18/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Kimberly, ThunderballTIME COMPLETED:
12:25 PM
NARRATIVE
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On 3/18/2024, at 9:55 AM, Licensing program analyst (LPA) Doni Fici arrived unannounced to conduct a 3 year required annual visit. Upon entry to the facility, LPA knocked on the door, knocked on the window, and rang the door bell. A staff member (Unknown name), answered the door and LPA informed the staff member the reason for today's visit. LPA was informed that the Licensee should be here in a few minutes and to wait till the Licensee arrives.

At 10:05 AM, Kimberly, Thunderbull, licensee arrived to the home and LPA informed the Licensee the purpose of the visit. Licensee refused to let LPA into the facility. LPA called Licensing program manager (LPM) Gladys, Kuizon and informed LPM the reason for calling. Licensee told LPM that she does not feel comfortable letting LPA into the home and is denying entry into the home. The Licensee was advised that a civil penalty would be issued if LPA is not allowed entry into the home.

A civil penalty is being assessed for todays visit of $500.00.

The following type A deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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 provided along with appeal rights.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/18/2024 12:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
102391(a)

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102391- Inspection Authority of the Department. (a) Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time...
This requirement is not met as evidenced by:
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Licensee will submit a written plan to CCL by POC due date.
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Based on interview, the licensee did not comply with the section cited above by not granting LPA entrance into the home to conduct a 3 year required annual inspection, which poses a potential health, 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: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2