<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414155
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:52:39 AM

Document Has Been Signed on 09/21/2022 10:52 AM - It Cannot Be Edited

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 PRESCHOOLFACILITY NUMBER:
434414155
ADMINISTRATOR:VIGIL, PATTIFACILITY TYPE:
830
ADDRESS:499 NORTH 11TH STREETTELEPHONE:
(408) 891-8730
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 12TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Mei YangTIME COMPLETED:
11:05 AM
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 Analyst (LPA), Cortney Nelson, met with Owner, Mei Yang, and explained purpose of visit. COVID risk assessment was conducted at the door prior to LPA entering the facility. Upon request for children's roster, LPA observed that it needed updating and advised Mei to update roster to reflect all children currently enrolled and submit to Licensing upon completion.

During today's visit, LPA observed that floor mats for infant napping are in disrepair and need replacement as foam is visible on some mats. LPA advised that all floor mats that have exposed foam or are taped together should be replaced for infant napping.

LPA additionally was informed by Mei that the previous Site Director, Patti Vigil, is no longer employed and a new Site Director, Carolina Dino, will be taking over the position. Mei states that she will have all documents submitted for the new director by Friday, 9/23/2022 and that it is within the 10 day requirement for reporting.

As a result of todays inspection, deficiencies were cited, see 809-D.

Exit interview conducted and report was reviewed with the Owner, Mei Yang.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 2
Document Has Been Signed on 09/21/2022 10:52 AM - It Cannot Be Edited


Created By: Cortney Nelson On 09/21/2022 at 10:13 AM
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: EMPIRE MONTESSORI PRESCHOOL
FACILITY NUMBER: 434414155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited

1
2
3
4
5
6
7
101239.1 Napping Equipment (b) Floor mats used for napping shall be: (5) Maintained in a safe condition with no exposed foam.

This requirement was not met as evidenced by:
8
9
10
11
12
13
14
The floor mats provided for infant napping were observed to have visible foam and taping, which is not maintained in a safe condition for infants which poses a potential risk for the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
The Owner will submit photo of removed floor mats and copy of order made for new floor mats by 9/30/2022.
Type B
09/26/2022
Section Cited

1
2
3
4
5
6
7
1596.841 Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Not all children present at the facility today were on the children's roster which poses a potential risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2