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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004883
Report Date: 04/27/2023
Date Signed: 04/27/2023 08:23:14 PM

Document Has Been Signed on 04/27/2023 08:23 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 BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EMPIRE PRESCHOOL SMFACILITY NUMBER:
414004883
ADMINISTRATOR:SARAH JENFACILITY TYPE:
850
ADDRESS:3080 LA SELVA STREETTELEPHONE:
(650) 678-3638
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 102TOTAL ENROLLED CHILDREN: 25CENSUS: 23DATE:
04/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sarah Jen and Bonnie LiTIME COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marie Rodriguez conducted an annual continuation inspection. LPA met with Director Sarah Jen and explained purpose of inspection. Present in the preschool program are the Director, two teachers, two teacher's assistants, and 23 preschool aged children. School is operating within capacity requirements and in compliance with child to staff ratio. Hours of operation are Monday to Friday from 8:00am to 6:00pm.

Four staff records were reviewed. Staff S4 has a criminal record clearance but is not associated to this license. Staff S3 and S4 have an incomplete personnel record and do not have a mandated reporter training certificate on file.

Facility representative was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com. If training is not available in native language, a statement can be written stating exemption until the translation is available.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (US DOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http:://www.ada.gov/childqanda.htm.

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.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EMPIRE PRESCHOOL SM
FACILITY NUMBER: 414004883
VISIT DATE: 04/27/2023
NARRATIVE
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Facility representative 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.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Deficiencies cited today under California Code of Regulations, Title 22, Division 12, which follows on LIC 809D.

LPA informed facility representative Bonnie Li that this report dated April 27, 2023 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the facility representative to provide a copy of this licensing report dated April 27, 2023 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with facility representative Bonnie Li. Appeals Rights were given.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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Document Has Been Signed on 04/27/2023 08:23 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 04:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMPIRE PRESCHOOL SM
FACILITY NUMBER: 414004883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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4
Facility representative will associate Staff S4 through Guardian website and will email LPA a copy of new roster by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2023 08:23 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 04:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMPIRE PRESCHOOL SM
FACILITY NUMBER: 414004883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Facility representative will provide LPA with a copy of mandated reporter training certificate for Staff S3 and S4 via email by the POC due date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Facility representative will provide LPA with a copy of signed LIC 503 for Staff S3 and S4 via email by the POC due date.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/27/2023 08:23 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 04:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMPIRE PRESCHOOL SM
FACILITY NUMBER: 414004883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
Facility representative will provide LPA with a copy of LIC 9052 for Staff S3 and S4 via email by POC due date.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
Facility representative will provide LPA with a copy of required documents as discussed for Staff S3 and S4 via email by the POC due date.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/27/2023 08:23 PM - It Cannot Be Edited


Created By: Marie Rodriguez On 04/27/2023 at 04:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMPIRE PRESCHOOL SM
FACILITY NUMBER: 414004883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
Facility representative will provide LPA with copies of Staff S3 and S4's TB tests results via email by the POC due date.
Type B
Section Cited
CCR
101217(a)(7)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (7) Past experience, including types of employment and former employers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review), the licensee did not comply with the section cited above in 2 out of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
Facility representative will provide LPA with a copy of LIC 501 for Staff S3 and S4 via email by POC due date.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


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