434415422-2-22-2023-07-CC-KMEO-CPATEZ-20230222134045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415422
Report Date: 02/22/2023
Date Signed: 02/22/2023 01:40:58 PM

Document Has Been Signed on 02/22/2023 01:40 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

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: 73	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Shimei Yang		TIME COMPLETED:	02:00 PM

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	On Febuary 22nd, 2023 at 11am Licensing Program Analyst (LPA) Kassandra Medrano met with Shimei Yang, Owner, for an unannounced required – 1-year annual inspection. LPA toured the indoor and outdoor areas of the Facility during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), menus, and Activity Schedule, and outdoor space waiver. Days and hours of operation are Monday through Friday, 8:30am-5:30pm. The preschool age program is Licensed in Rooms: 1, 2, 3 & 4. The following was observed today: Waivers on file is for outdoor space, and is posted for public review. Current facility director is Maria Socorro Jacalne. LPA reviewed ten children's and 8 staff files during today's inspection. Each child's file reviewed contains the required documents, including the Information and Emergency Information form (LIC 700) and immunization records. During review of staff files, it was observed that some staff files were missing documentation of mandated reporter training, as well as documentation of immunization's. Last fire/disaster drill was completed on 1/30/2023. The staff files that were reviewed have current CPR and First Aid certifications on file. Facility Representative understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). LPA observed that the teacher/child ratio was in compliance during today's inspection. Owner understands the conditions, limitations, and capacity specifications of the Facility license. Owner understand that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area. LPA observed that the facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. Director understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in the Facility and in the outdoor playground area via filtered water and personal water bottles. Staff and children's bathrooms are clean, sanitary, and operable. Owner states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors in the facility.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 434415422
	VISIT DATE: 02/22/2023

NARRATIVE

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The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. The facility provides snacks and lunch to children in care. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets or locked closets inaccessible to children. LPA observed a complete First Aid kit in the Facility, including a touch less thermometer. Director understands that smoking is not allowed on the Facility premises. This facility provides IMS. A review of storage of medications, equipment and supplies, and reviewed children, personnel and administrative records. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. LPA did not observe any bodies of water. Owner states that the Facility does not provide transportation.
Shimei, Owner, was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Owner, Shimei.
California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2023 01:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 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: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 7 staff were missing documentation of immunization which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2023
	Plan of Correction
1 2 3 4	Facility to send documentation of immnunizations for the 2 staff who are missing the documentation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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