434414155-9-21-2023-07-CC-AMOS-CVW5T4-20230921201344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414155
Report Date: 09/20/2023
Date Signed: 09/21/2023 08:14:01 PM

Document Has Been Signed on 09/21/2023 08:14 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:	434414155
ADMINISTRATOR:	CAROLINA DINO		FACILITY TYPE:	830
ADDRESS:	499 NORTH 11TH STREET		TELEPHONE:	(408) 891-8730
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	12	CENSUS: 7	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Carolina Dino & Mei Yang		TIME COMPLETED:	10:30 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 Analysts(LPA's) Anna Morales and Marilou Monico conducted an Unannounced Case Management inspection and was greeted by Director, Carolina Dino, and Owner, Mei Yang. Licensee has requested an application to increase the capacity from 12 to 24 infants, ages 6 weeks to 24 months, and relocate current Infant Room #4 to Room #3. Hours of operation will continue to be Monday-Friday, from 7:30 AM-6:00 PM. 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. LPA's observed that Room #3 is not completely furnished, however, Mei Yang stated that it will be completed before November 1, 2023. During the inspection, LPA's measured Room #3 and the Infant Playground: Room 3: 31.583 x 27.167 = 858.015 minus 192.774( encumbered space)= 665.241 Total Infant Indoor Space = 665.241 divided by 35 sq. ft =19 children Infant playground Measured: 30.00 x 27.917 = 837.51 minus 7.000 (encumbered space)7.000=830.51 Total Infant Outdoor Space = 830.51 divided 75 sq.ft.= 11 children Continue on page two-

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: 434414155
	VISIT DATE: 09/20/2023

NARRATIVE

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LPA's observed two sinks (30), one toilet (15), three tables, 19 chairs, 14 cots and 39 cubbies.

Prior to Licensure, Licensee will submit the following:
1. Playground Waiver along with playground schedule.
2. Updated Facility sketch along with updated Application for a Child Care Center License (LIC200A). Sketch is to include the partition of the infant bathroom and staff bathroom
3. Approved Fire Clearance for 19.
4. Notify Community Care Licensing (CCL) when classroom has been furnished.
5. Manager's final approval.

No deficiencies cited during today's visit.

Exit interview was conducted and report was reviewed with Director, Carolina Dino.

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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