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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415422
Report Date: 09/03/2019
Date Signed: 09/03/2019 12:52:31 PM

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:
434415422
ADMINISTRATOR:MARIA S & SHIMEI YFACILITY TYPE:
850
ADDRESS:585 WEST ALMA AVENUETELEPHONE:
(408) 505-7562
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:105CENSUS: 25DATE:
09/03/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maria JacalneTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Peter Tinkelenberg and Licensing Program Manager (LPM) Diana Stephenson met with owner Mei Yang and Director Maria Jacalne for a case management inspection. LPA and LPM observed 25 preschool children today, 12 children in room 1 with one teacher and 13 children in room 3 with two teachers.

During the inspection, LPA and LPM met with teacher Biridiana Valdivia who was found to be fingerprinted but not associated to the facility.

Type B deficiency was cited today and must be corrected by due date. Exit interview was conducted and appeal rights were discussed and reviewed with Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
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
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: 434415422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2019
Section Cited

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101170(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f)


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This requirement was not met as evidenced by:

Based on inspection of personnel records, it was observed that teacher Biridiana Valdivia did not have her fingerprint clearance transferred to this facility, which poses a potential risk to the health and safety of the children in care.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2019
LIC809 (FAS) - (06/04)
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