<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750054
Report Date: 05/25/2023
Date Signed: 05/25/2023 05:58:44 PM

Document Has Been Signed on 05/25/2023 05:58 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:EVO TAEKWONDO ACADEMYFACILITY NUMBER:
197750054
ADMINISTRATOR:THORNTON, KYLEFACILITY TYPE:
840
ADDRESS:43437 GADSDENTELEPHONE:
(661) 609-1568
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 42DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Kyle Thornton, LicenseeTIME COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Maddox conducted an announced visit today and met with Director, Kyle Thornton and Administrator Vanessa Thornton for the purpose of conducting an unannounced Required 1 year inspection. In addition, Director is requesting to increase the capacity with the addition of toilets and sinks.

The facility is located in a small strip mall. It is comprised of 4 classrooms, 1 music room, cafeteria, staff storage storage area, staff bathroom, 2 children's bathrooms (boys and girls), and training room (matted). This after- school program is for school age children (ages 5 - 12 yrs) which will specialize in Taekwondo, assist with homework, and music. Center will provide snacks only, menus posted. The hours of operation will be Monday thru Friday 7:30 am - 6:30 pm.



Children are escorted to the play yard, children will exit the center to access the play yard. LPA observed 1 large structure with sand underneath for cushioning material. The yard is 3/4 surrounded with chain link fencing.

LPAs observed fully charged fire extinguishers mounted throughout (carbon monoxide inclusive). LPA observed First Aid kits throughout the building.

Drinking water will be made available for children in the form of water bottles labeled with each child's name.

Office area will be used as the isolation area for sick children. The staff/adult bathroom will be used by sick children as well.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 05/25/2023 05:58 PM - It Cannot Be Edited


Created By: Donna Maddox On 05/25/2023 at 05:22 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: EVO TAEKWONDO ACADEMY
FACILITY NUMBER: 197750054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
1
2
3
4
During this inspection, Administrator, Vanessa Thornton sent out mass text to staff requesting to provide copies of current immunizations by POC due date
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
1
2
3
4
During this inspection, Administrator notified Staff #2 she's missing her Health Screening.
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 King
LICENSING EVALUATOR NAME:Donna Maddox
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/25/2023 05:58 PM - It Cannot Be Edited


Created By: Donna Maddox On 05/25/2023 at 05:22 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: EVO TAEKWONDO ACADEMY
FACILITY NUMBER: 197750054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(c)(1)
Teacher Qualifications and Duties
(1) Twelve postsecondary semester or equivalent quarter units in early childhood education or child development completed, with passing grades, at an accredited or approved college or university; and at least six months of work experience in a licensed child care center or comparable group child care program.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care. Staff files reviewed today did not contain copies of any transcripts
POC Due Date: 06/26/2023
Plan of Correction
1
2
3
4
During this inspection, Administrator Vanessa Thornton informed staff to provide copies of their transcripts. Administrator also stated this news came at a good time because a staff meeting is scheduled for this evening
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 King
LICENSING EVALUATOR NAME:Donna Maddox
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: EVO TAEKWONDO ACADEMY
FACILITY NUMBER: 197750054
VISIT DATE: 05/25/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INDOOR ACTIVITY SPACE:

· Disinfectants, cleaning solutions, are locked in a high cabinet in the girls bathroom.


· There is/are fully stocked first-aid kit(s) in locations accessible to staff but inaccessible to children:
· The isolation is located in the office for any child who becomes ill during the day.
· LPA observed operable carbon monoxide detectors and smoke detectors(hard wired). Fire extinguishers are located throughout the facility and fully charged.
· The center has a working telephone
· Sign-in and out procedure manual
RESTROOMS

All toilets and hand washing facilities shall be maintained in safe and sanitary operating condition. The Girls bathroom has 4 toilets and 3 sinks, the boys bathroom has 2 urinals, 2 toilets and 3 sinks

Staff bathroom- there is a staff bathroom that will also be used as an isolation bathroom

SUPERVISION:

Licensee shall ensure no child is left without the supervision of a teacher at any time, Supervision shall include visual observation.

TRANSPORTATION:

This center provides transportation

CHILDREN’S RECORDS:


LPA explained all children's records shall be available to the Department to inspect, audit, and copy upon demand during normal business hours.

FOOD SERVICES
This is an after school program that provides snacks only.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: EVO TAEKWONDO ACADEMY
FACILITY NUMBER: 197750054
VISIT DATE: 05/25/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
HEALTH RELATED SERVICES:

Medications shall be kept in a safe place inaccessible to children. Licensee has implemented a written plan to record the administration of prescription and nonprescription medications and to inform the child's authorized representative daily when such medications have been given.

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, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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

POSTINGS:

The Applicant/Licensee was informed of the required forms that shall be posted after licensure including the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5

Licensee is reminded of the requirement to report and unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC 624B.



Fire Clearance has been received for the requested capacity of 90 children.
2 Type B citations were issued today for lack of transcripts and lack of required immunization's for all staff. Capacity increase will be considered once transcripts for staff have been submitted to ensure the required teacher/child ratio's. Exit interview conducted, LPA printed out the requirements for SA teachers, and H&S regarding required immunization's.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5