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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414155
Report Date: 10/18/2023
Date Signed: 11/06/2023 11:26:08 AM


Document Has Been Signed on 11/06/2023 11:26 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:EMPIRE MONTESSORI PRESCHOOLFACILITY NUMBER:
434414155
ADMINISTRATOR:CAROLINA DINOFACILITY TYPE:
830
ADDRESS:499 NORTH 11TH STREETTELEPHONE:
(408) 891-8730
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:12CENSUS: 11DATE:
10/18/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Carlino DinoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA)Anna Morales conducted a follow up Case Management Licensee/Initiated inspection and was met with Carolina Dino,Director. The initial Pre licensing inspection was completed on 9/20/23 by LPA's Anna Morales and Marilou Monico. The purpose for today's inspection: Check the following physical plant items in Room 3 prior to Licensure:

1. A LIC200A and facility sketch was received and a FIRE CLEARANCE was granted on 10/12/23.

2. Director stated that they be placing a partition inside the bathroom( Room 3/4).

3. LPA observed nine sleeping cribs

4. Notify Community Care Licensing (CCL) when classroom has been furnished

5. Director will submit a Playground Waiver along with playground schedule.



6. Manager's review and approval.

No deficiencies cited during today's visit.

Exit interview was conducted and report was reviewed with Director, Carolina Dino.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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