Incident investigation·May 28, 2026

Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced Case Management Incident inspection at the above facility on 05/28/26 at 1:05 p.m. The purpose of this inspection is to follow up on an incident reported to the Department within 24 hours. At 1:10 p.m., LPA met with the facility representative Monica Bonilla who guided analyst on a tour of the facility and census was taken. During this inspection, LPA interviewed Staff 1 (S1) and Child 1 (C1). LPA also obtained a copy of the ouch report and doctor’s note. On 05/11/26, S1 was changing C1 diaper in the restroom and once the diaper change was done the staff opened the door, but the child’s hand was between the frame which caused the child to sustain a cut on their finger. According to the report, the staff cleaned the area, applied, ice and contacted parents. Staff also contacted the program nurse who advised to contact the parent for an early pick. During pick up, parent was advised to take C1 to the Emergency Room (ER) or urgent care. The facility was later notified that the child was taken to urgent care, glue was applied to the child's finger, and was cleared to return the following day with no restrictions. Interview conducted with S1 revealed that they were in the restroom with C1 changing their diaper and they were placing the dirty diaper in a plastic bag when they observed C1 near the door. S1 revealed that children sit in a chair located in the restroom; however, the day of the incident C1 got up from the chair once they saw S1 tie the plastic bag since the child knew that the bag would be thrown away and they would walk out of the stall. According to S1, C1 was grabbing the door and when the staff called the child over the child was startled and let go of the door since the door was not locked. S1 re-enacted their position including the position of C1. Page 1 of 2 Based on the re-enactment, it was observed that S1 couldn’t see that the child’s hand was in the door’s frame and when S1 called C1 the child was startled and released the door which slammed to their hand that was left on the frame. Per S1, then they heard the child say ouch and took the child to the sink to wash their hands. S1 then took C1 to sit at the table for lunch and observed that the child had blood smeared on their shirt which immediately assessed and cleaned the area. Per S1, they applied ice and observed a minor cut on the child's finger. S1 also stated that they called the program nurse who advised to call the child’s parent for an early pick up. According to S1, the incident occurred at approx. 2:00 p.m. which was near pick up. Parent of C1 arrived and was provided an ouch report and was advised to take the child to the ER or urgent care. S1 followed up with the parent of C1 who confirmed that the child was taken to urgent care and confirmed that there were no fractures. Parent of C1 provided a doctor’s note clearing the child to return to the facility the following day. LPA attempted to interview C1 who pointed to their finger and showed the LPA where they injured their finger; however, the child couldn't explain what happened. During today’s inspection, LPA toured the area where the incident occurred and observed 2 child sized chairs and procedures for diapering and changing soiled clothing procedures in the children’s restroom. According to S1, the incident happened so fast and will ensure that moving forward the restroom door will be locked to prevent future incidents/accidents. At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today. The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative, a civil penalty of $100 can be assessed. An exit interview was conducted, and a copy of this report was provided to the facility representative Monica Bonilla. Page 2 of 2