Incident investigation·April 28, 2026

On April 28, 2026, Licensing Program Analyst (LPA) Monique Ayala conducted an announced Case Management - Incident inspection at the above facility. LPA met with Assistant Director, Rebecca Adachi who guided LPA on a tour of the facility. LPA observed 38 infants with 11 staff members. The purpose of the inspection is to follow up on an incident that occurred on 03/26/2026 and was reported to the department on 03/27/2026; the incident was reported in a timely manner. During the inspection LPA interviewed Staff #1 (S1) to Staff #4 (S4) and obtained relevant documentation. LPA was unable to interview Child #1 (C1) as C1 is now attending the facilities sister licensed facility. Based on interviews with S1-S4, C1 was displaying normal behavior throughout the day. S1-S4 stated C1 ate, drank water and had normal wet diaper changes throughout the day (LPA obtained daily log). Per S1-S4 it wasn't until the end of the day that C1 started displaying drowsiness and eyes rolling back. Per S2-S3, S3 took C1 temperature and did not observe high levels (99). S2-S4 stated S1 directed them to call C1 parents. Per S4, they called C1 parents and they did not answer the call. S1-S4 stated the parent messaged the facility through BrightWheel informing S1-S4 that they would arrive at the facility within 5 minutes. Per S1-S4, upon the parents arrival, the parent asked if C1 ate and drank normally or if C1 had eaten anything different; S1-S4 confirmed yes to eating normally and no to nothing new/different. Parent signed out C1 at 5:06pm and left the facility. Per S1, the parent returned to the facility with C1 and sat in the courtyard area. Per S1, the ambulance and fire trucks arrived at the facility at 5:20pm. Per S1, S3-S4 they observed the parent and C1 leave with the paramedics. S1-S4 stated C1 did not return to the facility until the following Monday where S4 asked the parent how C1 was doing. Per S1, S3 and S4, C1 had low blood sugars and was dehydrated. Per S1, C1 was taken to the hospital on 03/26/2026 and had a check up with their pediatrician the following day. Per S1, parent informed them that C1 was not required to have further testing as test results came back normal. Per S1, C1 was transitioning to their sister facility and the facility developed an internal plan for C1 if this incident were to happen again. LPA observed C1's file and observed that the Physician Report was not completed or signed by the physician. The area where the physician is supposed to sign was signed by C1 mother. LPA was unable to determine if C1 had a prior health history of low blood sugars. The facility is being cited a Type B deficiency in accordance with Title 22 regulations, see LIC809D. An exit interview was conducted and a copy of this report was provided to assistant director, Rebecca Adachi. A Notice of Site Visit was provided and must be posted for 30 days.