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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414155
Report Date: 11/17/2023
Date Signed: 11/20/2023 09:50:16 AM


Document Has Been Signed on 11/20/2023 09:50 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: DATE:
11/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Carolina Dino/Mei YangTIME COMPLETED:
02:10 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 and Owner Mei Yang. 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. LPA observed a partition inside bathroom (Room 3/4), nine sleeping cribs, age appropriate toys/activities, and a diaper changing table that is placed within arm's reach of a sink.

Director has submitted a Playground Waiver along with playground schedule.

Approval pending on final review of Manager.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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