434414291-3-28-2024-07-CC-AMOS-D3SRWJ-20240328132314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414291
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:23:29 PM

Document Has Been Signed on 03/28/2024 01:23 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, 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: 4	DATE:	03/28/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Kimberly Thunderbull		TIME COMPLETED:	01:40 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 Analysts(LPA's) Anna Morales and Marilou Monico conducted an Annual Random inspection. LPA's were greeted by Licensee Kimberly Thunderbull. Also, present was her assistant and four children( three infants and one preschool aged child). Licensee was operating within her capacity and ratio requirements. LPA's observed the required postings, including the facility license inside the back living room. Days and hours of operation are Monday to Friday, 7:30AM to 5:00PM. The adults residing in the home is the Licensee, and her adult son. LPA reviewed a current Child Care Facility Roster. Licensee stated that she conducted a the last fire/disaster drill approximately three months ago, however was unable to locate the supporting documentation. Licensee state that she does have liability insurance for the day care. Licensee does not have a current Pediatric CPR and First Aid certifications. Licensee stated that she and her assistant will be completing this requirement on April 13,2024. Licensee has the required vaccines (MMR, Tdap on file), however, is not certain if she will be taking the flu immunization or opt out). Licensee state that a child will be isolated from the other children in the play room if necessary due to illness or communicable disease until a parent/guardian is able to pick them up. LPA's observed sufficient materials, toys, and play equipment for the day care children. Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPA's observed play equipment were in good condition. LPA's observed that the structured swing set/climbing structure was secured. Drinking water was readily available to children indoor and outdoor. The home is clean, orderly, and safe for the day care children. LPA's did not observe any wall heaters inside the home. There is a covered fireplace inside the living room. Off-limit areas inside: the entire upstairs of the home, kitchen and the entire right side of the house. Off-limit areas outside: the garage and the right side. Observed barricade in front of stairs.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: THUNDERBULL, KIMBERLY	FACILITY NUMBER: 434414291
	VISIT DATE: 03/28/2024

NARRATIVE

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LPA's observed a fully charged 3-4ABC fire extinguisher, working smoke/carbon monoxide detectors, and the fenced area where the day care is. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that she does not administer any medications to the day care children.

Licensee stated that she provides breakfast ,lunch and snacks. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the day care. Licensee stated that nobody smokes, and she understands that smoking is prohibited in the day care .

LPA's reviewed four(4) child's file which were missing required documentation. LPA's observed the that 15 minutes sleep log for three infants were not completed and one did not have an Individual Infant Sleep care plan on file.

LPA's observed staff(assistant) file. Observed Criminal Record Statement, Employee rights, and LIC9108( Statement Acknowledging Requirement to Report Child Abuse. LPA's were unable to review Immunization records(including the flu/flu opt), Mandated Reporter Training and Current Pediatric First Aid/CPR.

Licensee stated that she does provide transportation for school age transportation. LPA's observed that Licensee has a current Drivers License. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

The licensee understands that children's personal rights should not be violated, including no unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Supervision of children was discussed with the Licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the day care . Licensee states that she does not transport any day care children.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: THUNDERBULL, KIMBERLY	FACILITY NUMBER: 434414291
	VISIT DATE: 03/28/2024

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Licensee was reminded that all adults 18 and over living or working in the home/ day care, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days/$3000.00 per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

LPA's discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPAs also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LPA's informed Licensee that sleep sacks and loose objects including stuffed animals are not allowed for infants who are sleeping , and the door must remain open if no staff are present while the children are sleeping in a separate room.
LPA's informed Licensee that Baby bouncers are not allowed.

LPA's encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates. The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with the Licensee and deficiencies were cited at today's were issued during today's inspection. Appeal Rights Given.
A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 01:23 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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee stated she conducted her last drill approximately three months, however, does not have documentation, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a copy of a diaster drill to CCL by the POC date.

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 Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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
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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee stated that she has not documented the 15 minute checks for infants(C1, C2 and C4),which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a plan to ensure that she is compliance with Infant Safe Sleep regulations, which is to include the 15 minute checks for sleeping infants to CCL by the POC Date.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,the licensee did not comply with the section cited above. Licensee and S1 do not have a current Mandated Reporter Training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit a copy of the Mandated Reporter Training to CCL by the POC date.

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 Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 01:23 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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. S1 does not have immunization records(Pertussis, Measles, Flu) on fil, which poses a potential risk to the health and safety and personal rights to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit a copy of S1 immunization records to CCL by the POC date.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee and S1 do not have current Pediatric CPR/FIRST Aid, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2024
	Plan of Correction
1 2 3 4	Licensee will submit copies of the Pediatric CPR/FIRST AID to CCL by the POC date.

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 Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 01:23 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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's were unable to review six children's files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit the required forms for the six children to CCL by the POC date.

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. Licensee did not complete a LIC9227 for C4, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit the LIC9227(Individual Infant Sleeping Plan) to CCL by the POC date.

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 Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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