013420938-5-19-2023-52-CC-AWRT-CRYUR2-20230519154802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420938
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:48:09 PM

Document Has Been Signed on 05/19/2023 03:48 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	EMPIRE MONTESSORI PRESCHOOL		FACILITY NUMBER:	013420938
ADMINISTRATOR:	SHIMEI YANG		FACILITY TYPE:	850
ADDRESS:	3765 WASHINGTON BLVD		TELEPHONE:	(510) 979-1696
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 120	CENSUS: 46	DATE:	05/19/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	July Galaraga		TIME COMPLETED:	03:55 PM

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On May 19th, 2023 @ 2:10pm, Licensing Program Analyst (LPA) April Wright arrived for Case Management visit and met with Director July Galaraga. Purpose of the visit is to follow up on an incident where a child was injured during play time at the facility. Present during today's visit are 46 preschool age children and 6 staff personnel. LPA toured the facility for a health and safety inspection.

NAME/ AGES (DOB) OF CHILDREN INVOLVED: Brady Wong - DOB: 12/24/2019 / Renee Wong DOB: 1/17/2020 (injured child)

PARENTS: Eric Zhao / Helen Wong - Parents

WITNESSES: Teacher Jiahui "Kari" Huang and Teacher Lisa

On April 11th, 2023 @ 4:30 pm, Center director July Grace Galaraga called to CCLD that children Renee and Brady were sitting on the children's bench during play time. Renee jumped quickly on top of the bench and Brady followed her, resulting in both children falling off the bench. Teacher Kari and Teacher Lisa were both present on the yard and witnessed the incident. Director called parents and child was taken to Washington Hospital for treatment. Center Director accompanied Mother of child to the emergency room. Internal Accident report was completed and given to parents on day of incident.

Center director advised that child's right arm was broken and a was placed in a temporary cast in the emergency room. Child's parent's will follow up with pediatrician in the following days for permanent cast. Child's arm was placed in a permanent cast on April 17th, 2023.

Per Center Director the incident was caught on facility video and LPA reviewed video during visit, director will forward video evidence to LPA. Center Director called in incident within 24hrs and followed up with LIC624 via email to LPA within 7 days of the incident. See LIC809C for continuance.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: EMPIRE MONTESSORI PRESCHOOL	FACILITY NUMBER: 013420938
	VISIT DATE: 05/19/2023

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On April 28th, 2023, Center director contacted LPA to advise that Parents of Renee Wong have advised legal council and possibly take legal action against facility for the injuries and daycare tuition fees. Director sent LPA log of all contacts they have had with the parents and supporting documents of the incident.

Director contacted Owner ShiMei Yang to forward over additional supportive information and documentation to incident report. LPA will attach supportive documents to LIC812 once it has been received. LPA interviewed Teacher Jiahui "Kari" Huang and Teacher Lisa regarding the incident.

LPA gave copy of report to Center Director and notice of site visit given.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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