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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410825
Report Date: 10/18/2023
Date Signed: 11/06/2023 11:26:51 AM

Document Has Been Signed on 11/06/2023 11:26 AM - 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:EMPIRE MONTESSORI PRESCHOOLFACILITY NUMBER:
434410825
ADMINISTRATOR:CAROLINA DINOFACILITY TYPE:
850
ADDRESS:499 NORTH 11TH STREETTELEPHONE:
(408) 295-5900
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 68TOTAL ENROLLED CHILDREN: 68CENSUS: 44DATE:
10/18/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Carolina DinoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA)Anna Morales conducted a follow up Case Management/ Licensee Initiated inspection and met with Carolina Dino, Director. The initial Pre licensing inspection was completed on 9/20/23 by LPA's Anna Morales and Marilou Monico. The purpose for today's inspection for Room 4: Check the following physical plant items prior to Licensure

1. A LIC200A and facility sketch was received and a FIRE CLEARANCE was granted on 10/12/23.

2. Notify Community Care Licensing (CCL) when classroom has been furnished



3. Manager's review and approval.

No deficiencies cited during today's visit.

Exit interview was conducted and report was reviewed with Director, Carolina Dino.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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