434410825-7-28-2021-07-CC-AMOS-C5CL34-20210728082320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410825
Report Date: 07/27/2021
Date Signed: 07/28/2021 08:23:27 AM

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:	EMPIRE MONTESSORI PRESCHOOL		FACILITY NUMBER:	434410825
ADMINISTRATOR:	MARTA VIGIL		FACILITY TYPE:	850
ADDRESS:	499 NORTH 11TH STREET		TELEPHONE:	(408) 295-5900
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	68	CENSUS: 18	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Patti Vigil		TIME COMPLETED:	04:00 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	#1 Licensing Program Analysts (LPA) Anna Morales conducted an unannounced Annual Required inspection. LPA met with Assistant Director, Patti Vigil. Facility's License, Notification of Parents’ Rights Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. The center's operating hours are Monday through Friday from 8:00AM to 05:00 PM. Age serve is 2 years to entry into first grade. Last disaster drill was conducted on April 26, 2021. The Preschool Program is operating in Rooms 1 and 2. LPA observed one teacher including Site Director supervising 18 children. Children were observed napping during this visit. LPAs toured the facility both indoor and outdoor. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. There were no bodies of water observed. Assistant Director stated that facility do not have weapons on the premises. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean. Outdoor activity space is enclosed by fencing and is observed to be free of hazards. LPA observed play equipment were in good condition. LPAs observed resilient materials under the climbing structures. Drinking water was readily available to children indoor and outdoor. Activities schedule was posted. Facility is not providing lunch or snacks due to COVID. (page 1)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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 3

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: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 434410825
	VISIT DATE: 07/27/2021

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
26
27
28
29
30
31
32

Foods and beverages were kept protected against contamination and spoilage. Trash cans for solid waste had tight-fitting covers on, and were in good repair. Fire extinguisher was observed inside the front hallway. The smoke and carbon monoxide detectors are hard wired.

This facility is providing Incidental Medical Services – IMS Plan. Assistant Director stated that none of the children currently enrolled are using medications.

LPA reviewed sign in and out record, and procedure. A sampling of children and staff files was taken for review during today's inspection. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Medical Assessment and Immunization.

Staff records reviewed include Criminal Record and Child Abuse Index Clearance, Health Screening Report and TB test, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Site Director that the online AB1207 Mandated Reported Training needs to be renewed every two years. There was at least one person with current certification in Pediatric CPR and First Aid present at the facility.

LPA reminded Assistant Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

LPA also reviewed with Assistant Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Assistant Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 434410825
	VISIT DATE: 07/27/2021

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
26
27
28
29
30
31
32

In the areas that were evaluated, there were no deficiencies cited.

A copy of this report was provided to the facility at the conclusion of the inspection. Site Director has agreed to submit to LPA, a copy of Client Roster, Mandated Reporter, First aid and CPR.

NOTICE OF SITE VISIT WAS ISSUED. SITE DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3