434415422-9-3-2019-07-CC-DSTN-BHG7HV-20191030214120

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415422
Report Date: 09/03/2019
Date Signed: 09/03/2019 12:50:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2019 and conducted by Evaluator Peter Tinkelenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20190826132818

FACILITY NAME:	EMPIRE MONTESSORI PRESCHOOL		FACILITY NUMBER:	434415422
ADMINISTRATOR:	MARIA S & SHIMEI Y		FACILITY TYPE:	850
ADDRESS:	585 WEST ALMA AVENUE		TELEPHONE:	(408) 505-7562
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	105	CENSUS: 25	DATE:	09/03/2019
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maria Socorro Jacalne		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility outdoor playground equipment is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Peter Tinkelenberg and Licensing Program Manager (LPM) Diana Stephenson conducted an unannounced complaint inspection today. At 8:30 AM we met with Director Maria Jacalne who invited us into her office to discuss the nature of the complaint. The LPA and LPM toured the facility with the Director who showed us the classrooms and playground. The LPA and LPM observed 12 preschool children in room 1 with one teacher and 13 preschool children in room 3 with 2 teachers. Owner Shimei Yang joined at 11:30 AM.
The LPA and LPM inspected the play structure and observed that one plastic barrier to prevent children from falling off the raised platform was replaced by a wooden board held in place by strings tied to the post on each side of the board, which is not stable and secure. Based on observation, and a discussion with the director who stated that the wooden board has been in place for a week as she waits for the replacement barrier. Violations of the California Code of Regulations, Title 22, Division 12, Chapter 1, Article 07. A Type B deficiency is being cited on the attached LIC 9099D. The preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTATIANTED.
Exit interview conducted and copy of this report provided to the facility. A Notice of Site Visit was provided and must be posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter Tinkelenberg	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20190826132818

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 09/10/2019 Section Cited CCR 101238(a)	1 2 3 4 5 6 7	101238(a) Buildings and Grounds: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	By 5 PM September 10, 2019, Director Maria Jacalne will provide the LPA a picture of the new barrier as evidence that the wooden barrier was replaced by an original play structure barrier. Within 10 days after the POC date, the LPA will come to inspect the play structure to inspect the barrier.
	8 9 10 11 12 13 14	Based on the inspection of the outdoor play structure, Director Jacalne failed to maintain the safety of the play structure by using a substitute wooden barrier in place of the original plastic barrier, which poses a potential risk to the health and safety of the children in her care. The wooden barrier was held in place by strings which allowed the barrier to be pushed open.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter Tinkelenberg	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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