Incident investigation·October 17, 2025

On the date and time listed above, Licensing Program Analyst (LPA) Raymond Moorehead arrived at the facility to conduct a case management inspection. LPA met with Acting Assistant Director Janelle Velez. A case management inspection was conducted in response to the receipt of an Unusual Incident Report (UIR) from the facility. The UIR was received by the licensing agency on 10/10/2025. During the course of the visit, LPA conducted interviews and collected documentation. The following was disclosed. The facility self-reported an incident in which Child 1 was mistakenly given medication that was prescribed to Child 2. According to statements received during interviews, the subject staff member entered the classroom to administer medication and announced that they were there for the purpose of administering medication. Then, it was stated that the classroom’s teacher pointed toward Child 1, who then approached and accepted the medication without hesitation. It was also stated that after administration of the medication, the subject staff member and classroom's teacher realized that the medication was intended for Child 2. Child 1’s parent was notified and took the child to the doctor as a precaution. The child was evaluated, found to be okay, and later returned to care without further incident. As a corrective measure, the facility has implemented new procedures to prevent future medication errors. It was stated that a new signature line has been added to medication forms to serve as a double-verification method, ensuring that medication is administered to the correct child. In addition, it was stated that management staff have been retrained on proper medication administration procedures and verification protocols to reinforce compliance and accountability. It was also stated that moving forward, children will be required to take medication in the front office, administered only by management staff. See LIC 809-C. The incident described above was found to be in violation of Title 22 Regulation, Section 101223(a)(2), relating to the Personal Rights of children care, to be accorded safe, healthful and comfortable accommodations . See LIC809-D for cited deficiency. LPA informed the facility representative that this report dated 10/17/2025 documents 1 Type A citation, which shall be posted for 30 consecutive days as there was an immediate risks to the health, safety, and personal rights of children in care. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Also, LPA informed the facility representative to provide a copy of this licensing report dated 10/17/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Exit interview conducted and report was reviewed with Acting Assistant Director Janelle Velez.