434414155-7-28-2021-07-CC-AMOS-C5CL45-20210728082459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414155
Report Date: 07/27/2021
Date Signed: 07/28/2021 08:25:05 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:	434414155
ADMINISTRATOR:	VIGIL, PATTI		FACILITY TYPE:	830
ADDRESS:	499 NORTH 11TH STREET		TELEPHONE:	(408) 891-8730
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	12	CENSUS: 4	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 Analyst (LPA) Anna Morales conducted an Unannounced Annual Visit and was greeted by Site Director, Patti Vigil. Also present were two teachers. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), and Activity Schedules. Last disaster drill was conducted on April 26.2021. Facility operating hours are Mon-Friday, 8am- 5:00pm. Infant Program is operating in Room 4. There were four infants over the age of twelve months napping and one teacher present. The children in the Infant Program use Infant/Toddler and Toddler Playgrounds. LPA observed that each infant has current feeding, diaper, and nap log. The center has documentation that sleeping infants were checked every 15 minutes. Diapers are being disposed appropriately. Each infant has personal items individually stored and labeled. LPA toured the facility both indoor and outdoor. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. Two infants were engaged in quiet time activities and two were napping under the supervision of staff. There were no bodies of water observed. Site Director stated that the 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 spaces are enclosed by fencing and are observed to be free of hazards. LPA observed play equipment were in good condition. Drinking water was readily available to infants indoor and outdoor, Facility is not providing lunch and snacks due to COVID. (page one)

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)

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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 434414155
	VISIT DATE: 07/27/2021

NARRATIVE

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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. Smoke and carbon monoxide detectors are hardwired. Fire extinguisher was observed in front hallway.

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

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, Immunization, and Infant Needs and Services Plan.

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 Assistant 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 Site 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 Site 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.
(page 2)

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: 434414155
	VISIT DATE: 07/27/2021

NARRATIVE

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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.

LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) OF FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES.

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)

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