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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415422
Report Date: 10/20/2023
Date Signed: 10/20/2023 12:28:19 PM


Document Has Been Signed on 10/20/2023 12:28 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:EMPIRE MONTESSORI PRESCHOOLFACILITY NUMBER:
434415422
ADMINISTRATOR:MARIA S & SHIMEI YFACILITY TYPE:
850
ADDRESS:585 WEST ALMA AVENUETELEPHONE:
(408) 505-7562
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:105CENSUS: 48DATE:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shimei YangTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Mel Matos and Jessica Bongardt met with Shimei Yang, Licensee representative/director, for an unannounced case management investigation in response to an Unusual Incident that the Facility self reported to the Department.

LPAs interviewed Shimei, one employee, and reviewed facility documents during today's investigation. Further investigation is required at this time and the investigation is Continuing.

Exit interview conducted and report was reviewed with Licensee representative/director, Shimei Yang.

No deficiencies issued during today's inspection. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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