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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750055
Report Date: 08/09/2022
Date Signed: 08/09/2022 05:48:49 PM


Document Has Been Signed on 08/09/2022 05:48 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:ONE TAEKWONDO, THEFACILITY NUMBER:
197750055
ADMINISTRATOR:KIM, HYOSEOPFACILITY TYPE:
840
ADDRESS:26246 BOUQUET CANYON ROADTELEPHONE:
(661) 673-3396
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:30CENSUS: 43DATE:
08/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Noelle Efflandt TIME COMPLETED:
06:05 PM
NARRATIVE
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On 08/09/22, Licensing Program Analysts (LPAs) Justeene Tamayo and Barbara Beneroso met with staff Noelle Efflandt for the purpose of conducting a Case Management inspection. Upon arrival, LPAs observed 24 school age children, and staff #1 present. About fifteen minutes later, staff #2 and Director #1 came to the facility with 13 more school age children. LPAs reviewed the facilities emergency disaster plan.

During initial walk through, the above facility was out of ratio. A teacher shall supervise no more than 14 children. LPAs observed 24 school age children to 1 staff member. A Type A citation will be assessed due to an immediate health and safety risk to children in care. Please see LIC809-D

After file review and observation, there is a total of 43 school age children with a capacity of 30 school age children that are allowed in the facility. LPAs obtained the facilities sign in sheet for today 08/09/22. This is a violation of the fire clearance granted by the State Fire Marshall. A Type A citation will be assessed due to an immediate health and safety risk to children in care. Please see LIC809-D. A civil penalty of $500 will also be assessed.

An hour into the inspection, LPAs observed staff #3, staff #4, and staff #5 enter the facility. LPAs observed staff #3, staff #4, and staff #5 interact and assist the children present in the day care facility without a fingerprint clearance. LPAs observed the school age day care children go back and fourth from the day care area to the taekwondo area to interact with the taekwondo instructors who are not fingerprint cleared. This poses an immediate health and safety risk to children in care. A type A citation will be assessed, as well as an immediate civil penalty of $1500 will be assessed.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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Document Has Been Signed on 08/09/2022 05:48 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited

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Teacher-Child Ratio 101516.5 (1): A teacheer shall supervise no more than 14 children. This requirement is not met as evidence by:
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LPAs observed 24 school age children supervised by staff #1. This poses an immediate health and safety risk to children in care.
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Type A
08/09/2022
Section Cited

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Capacity Determination 101179(a):A license shall be issued for a specific capacity, which shall be the maximum number of children that can be cared for at any given time.This requirement is not met as evidence by:
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LPAs observed a total of 43 school age children, which is over the required capacity of 30 preschool children issued by the Fire State Marshall for this facility. This poses an immediate health and safety risk to children in care.
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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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2022 05:48 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2022
Section Cited

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Reporting Requirements 101212(d)(1)(G): Upon the occurrence, during the operation of the child care center of any of the events… a report shall be made to the Department by telephone or fax within the Department's next working day…. a written report containing the information…shall be submitted to the Department within seven days following the occurrence.. Events reported shall include the following…Catastrophes. This requirement was not met as evidenced by:
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Based on interview and record review, The above facility failed to notify the Palmdale Regional Office of an unusual incident that caused 24 children and a number of staff to evacuate the premises due to the Railroad Fire that happened on 08/06/22.
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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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055
VISIT DATE: 08/09/2022
NARRATIVE
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On 08/06/22, The Palmdale Regional Office received a notification from the Disaster Service Bureau of a fire (Railroad Fire) in Los Angeles County in the city of Santa Clarita. The above facility was under mandatory evacuation as there was a fire close by. 24 children and staff were ordered to be evacuated across the street to a safe location. The evacuation lasted for 1 hour. The above facility failed to report this unusual incident to the Palmdale Regional Office.

The facility was not in compliance per Title 22 regulations. A Type B deficiency will be cited today. Please see LIC809-D for citation assessed. LPAs provided technical assistance regarding Disaster preparedness and Disaster Reporting Procedures during issuance of citation.

An exit interview was conducted with Director Kyra Oakley, along with her appeal rights. A Notice of Site Visit posted. Failure to maintain posted for 30 Days will result in an immediate civil penalty.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/09/2022 05:48 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited

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Criminal Record Clearance 101170(e)(1): All individuals subject to a criminal record review pursuant to Health and Safety Code Section...shall prior to working, residing or volunteering in a licensed facility....Obtain a California clearance or a criminal record exemption. This requirement was not met as evidence by:
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Based on observation and interview, LPAs observed staff #3, staff #4, and staff #5 interact and assist with the school age children. This poses an immediate health and safety risk to children in care.
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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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5