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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412013
Report Date: 10/22/2025
Date Signed: 10/22/2025 02:06:54 PM

Document Has Been Signed on 10/22/2025 02:06 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:GILROY UNIFIED SCHOOL DISTRICT ROD KELLEY PRE.FACILITY NUMBER:
434412013
ADMINISTRATOR/
DIRECTOR:		GAYLE DARRFACILITY TYPE:
850
ADDRESS:8755 KERN AVENUETELEPHONE:
(669) 205-4700
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 24TOTAL ENROLLED CHILDREN: 23CENSUS: 12DATE:
10/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Carolina La Ra MendozaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/22/2025, Licensing Program Analyst (LPA) Liridon Fici- Doni conducted an unannounced case management visit for an incident that occurred on 10/3/2025. LPA was greeted by staff- Carolina La Ra Mendoza and informed her the purpose of visit. Shortly after, at 9:45AM, Beatrice Magdaleno, Early Childhood Administrator (ECA) arrived and met with LPA. LPA took a census of children present.

During todays visit, LPA conducted interviews with staff. Based on interviews, LPA was informed by Staff 2- S2 that Staff 1- S1 initially kicked Child 1- C1 on 10/1/2025 and did not mention anything because S2 thought it was an accident. On 10/3/2025, both S2 and Staff 3- S3 witnessed S1 kick C1 on the foot and S2 and S3 both confirmed the incident. After C1 was kicked, S3 moved C1 away from S1 to avoid being kicked again. On 10/6/2025, C1 was sitting next to S1 and S2 witnessed S1 kick C1 twice and S2 informed the ECA about the incident. Staff stated C1 did not cry nor acknowledge being kicked. ECA conducted an investigation dated from 10/6/25 through 10/8/25.

The following type B 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 and report was reviewed with the ECA, Beatrice Magdaleno.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/22/2025 02:06 PM - It Cannot Be Edited


Created By: Liridon Fici On 10/22/2025 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GILROY UNIFIED SCHOOL DISTRICT ROD KELLEY PRE.
FACILITY NUMBER: 434412013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2025
Section Cited
CCR
101223(a)(1)

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101223(a)(1)- Personal Righs: (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
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Licensee agreed to conduct all staff training regarding personal rights of children to be signed by all staff, and to send a reminder follow up email to Staff 1 (S1) about personal rights of children in care. A copy of all staff training and the follow up email will be submitted to CCL by POC due date as proof.
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Based on interviews, the licensee did not comply with the section cited above because Child 1 (C1) was kicked on the foot on 10/1/25, 10/3/25, and on 10/6/25 by Staff 1 (S1) during circle time which poses a potential, 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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Liridon Fici
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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