434410825-9-21-2023-07-CC-AMOS-CVW5SA-20230921201223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410825
Report Date: 09/20/2023
Date Signed: 09/21/2023 08:13:01 PM

Document Has Been Signed on 09/21/2023 08:13 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:	EMPIRE MONTESSORI PRESCHOOL		FACILITY NUMBER:	434410825
ADMINISTRATOR:	CAROLINA DINO		FACILITY TYPE:	850
ADDRESS:	499 NORTH 11TH STREET		TELEPHONE:	(408) 295-5900
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	68	CENSUS: 25	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Carolina Dino/Mei Yang		TIME COMPLETED:	12:30 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 unannounced Case Management Inspection. LPAs met with Director, Carolina Dino, and Owner, Mei Yang. Licensee has requested an application to decrease the capacity from 68 to 56, and relocate current Preschool Room #3 to #4. Rooms 1 and 2 will remain the same, and hours of operation will continue to be Monday-Friday, 7:30 AM -6:00 PM, ages 2 years to entry to 1st grade. Room #3 is currently licensed for a Preschool classroom(#434410825) and is not in use by the children. Fire clearance has been granted on 8/9/2023. During today's visit, LPA's measured Room #4 and Preschool Playground. Indoor measurements are as follows per LPA Janet Tse report dated 06/12/2014: ROOM 1: 31.249 x 27.332 = 854.097 minus 21.805 (encumbered space) = 832.292 ROOM 2: (15.581 x 14.747) + (24.498 x 20.249) = 725.833 minus 15.433 (encumbered space) = 710.400 Indoor measurements are as follows taken by LPA's Anna Morales and Marilou Monico during today's inspection: ROOM 4: 27.500 x 16.667= 458.342 minus 33.263 (encumbered space)=425.079 TOTAL PRESCHOOL INDOOR SPACE: 1,967.771 divided by 35 sq.ft. = 56 children Preschool Playground: 103.917 x 29.750 = 3,091.530 minus 139.80 (encumbered)=2,951.73 TOTAL PRESCHOOL OUTDOOR SPACE = 2,951.73 divided by 75 sq.ft = 39 children continue on page 2

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 434410825
	VISIT DATE: 09/20/2023

NARRATIVE

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LPA's observed a total of 8 sinks(120) and 5 toilets(75), 60 cubbies, 70 cots, and 9 tables and 60 chairs. There is a bathroom for staff and for children who are sick. Sick children will be isolated in the Office and isolation equipment will be provided.

The following items to be completed prior to licensure of 56 children in the preschool program:
1) Manager's review and approval.
2) Updated facility sketch.

Exit interview was conducted with Director Carolina Dino. No deficiencies were cited at today's visit.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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