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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750055
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:23:09 PM


Document Has Been Signed on 10/06/2023 05:23 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
PALMDALE CC RO, 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: 18DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Kyra Oakley, DirectorTIME COMPLETED:
05:35 PM
NARRATIVE
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On Friday, October 6, 2023, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with director Kyra Oakley who guided LPA Rivera on a tour of the facility.

This is a school-age program that serves children ages 5 to 14 years. This program operates Monday to Friday 2:00 p.m. – 6:00 p.m. for after school care. Sign out takes place at the main entrance area. All areas identified on the facility sketch were toured and inspected. Teacher and child ratio were observed, and present staff are fingerprinted cleared. LPA reminded director; annual fees are due. LPA provided the PIN for director to pay online.



At approximately 3:00 pm. LPA entered daycare room area. LPA Rivera observed 18 children with staff #3 and staff #4 present supervising the children. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed personal bins for children to store their personal belongings. LPA observed cleaning solutions stored inside the storage room behind storage equipment making it inaccessible for children to reach. LPA Rivera observed the trash bins with no lids and informed director bins need tight lids.

Heating, lighting and ventilation were evaluated by LPA Rivera. LPA observed central AC/heater and vents located on the ceiling. LPA observed the thermostat and temperature to be 76 degrees. LPA observed the fire extinguishers located in classrooms and the valve on the required 2A10BC fire extinguishers indicating fully charged and serviced on 6/24/2023. Smoke and carbon detectors were not tested during this visit due to the detectors being wired to the emergency pull down fire alarm system. LPA did not observe emergency drill and informed director, drill must be conducted every six months and document. First aid kit supplies are kept inside the classrooms and LPA observed the kits to be fully equipped. During this visit, director stated one child currently has an EPI Pen. LPA Rivera reviewed the EPI Pen and did not observe an expiration date. LPA advised for parent to provide Dr prescription with an expiration date. LPA Rivera asked if there were any poisons, firearms, weapons or bodies of water. Director Kyra stated no firearms, weapons, no poisons nor
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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Document Has Been Signed on 10/06/2023 05:23 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in not testing the drinking water which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Per director Kyra, she will schedule for an inspection to test the drinking fountains by due date.
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 staff #2, #3 and #4 not having the AB 1207 Child Abuse Mandated Certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Per director Kyra, will have staff #2, #3, and #4 submit their AB 1207 Child Abuse Mandated Certification by 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: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2023 05:23 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

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 not providing proof of the Pediatric First Aid/CPR certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Per director Kyra, will submit proof of Pediatric First Aid/CPR certification by 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: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055
VISIT DATE: 10/06/2023
NARRATIVE
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bodies of water. LPA did not observe firearms or weapons, poisons, nor bodies of water. Director stated the ill isolation area takes place in the director’s area and children utilize staff restroom. LPA observed two individual restrooms. LPA Rivera observed the restrooms to be in good condition with working toilets, sinks, hand soap dispenser and paper towels. LPA observed a total of 2 toilets and 2 sinks.

No outdoor play area. Waiver on file to utilize local parks. Facility provides transportation and parents provide the car seats and booster seats.



This program does not provide meals or snacks. LPA Rivera informed director that any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. For water drinking, LPA Rivera observed water fountain and children refill their water bottles. Facility has not conducted Lead testing. LPA informed facility needs to test the water for lead.

The following documents were posted in a prominent, publicly accessible area at the facility: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and Earthquake Preparedness (LIC 9148). PUB 269 Child Passenger System Poster.

LPA Rivera reviewed children’s files and staff files. LPA Rivera did not review the children roster due to not being available. LPA did not observe staff or director Pediatric First Aid/CPR certification. LPA informed one staff with a valid Pediatric First Aid/CPR certification must be present at all times.



LPA Rivera observed director Kyra Preventative Health and Safety certification dated 12/2/2018 and has proof of immunization against Pertussis, MMR and Influenza declination. Director has completed the mandated reporter (AB 1207) training dated 6/14/22. Director was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com
Items discussed during this visit:

1. The following items are prohibited by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055
VISIT DATE: 10/06/2023
NARRATIVE
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2. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.


4.LIC 311A - Records to be Maintained at the Facility: LPAs advised that forms, regulations and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.

5.Pediatric First Aid and CPR: At least one person trained in Pediatric First Aid and CPR and EMSA approved must be present.

6.Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7.Qualifications: Educational background, training, and/or experience for each staff present must be available for review

8. Immunization Requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles or influenza declination

9.Children’s Records: must be available for review; including but not limited to, the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

Director Kyra was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ONE TAEKWONDO, THE
FACILITY NUMBER: 197750055
VISIT DATE: 10/06/2023
NARRATIVE
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LPA referred director Kyra to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

Director Kyra was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

The deficiencies listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Title 22. Three type B deficiencies are being issued today. See attached LIC 809-D for citation.

Three technical violations are being issued today. See attached Technical Violations LIC 9102.

A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report was reviewed with director Kyra Oakley.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9