Incident investigation·November 25, 2024

On November 25, 2024, at 02:00pm, Licensing Program Analyst (LPA) Kendal Zirbes conducted an announced office visit with Administrator Lisa Burtner. The purpose of the office visit was to address a self-reported unusual incident report (UIR) submitted to the Department on October 28, 2024. Over the course of investigating the unusual incident, LPA completed an unannounced inspection of the Center on November 8, 2024, and completed confidential interviews with staff and parents. In addition, a review of the Center records was completed which included photographic evidence. On October 28, 2024, the Department received a UIR from the Center regarding marks under and around child 1 (C1) arms. Information obtained during the Departments investigation revealed an incident occurred in the infant outdoor activity space on October 25, 2024. During the incident, staff 1 (S1) was providing supervision to four infants. While laying on a blanket on the sand, C1 rolled over face first into the sand. Interviews provided inconsistent information as to how S1 reacted when C1 rolled into the sand. Some interviews reported S1 grabbed C1 by the arm and wrist pulling C1 back onto the blanket. S1 denied grabbing C1 roughly and stated S1 quickly lifted C1 up from under the arm pit area. Information obtained reported C1 was wearing a onesie on October 25, 2024, and C1 was not changed out of C1 clothes the entire day, therefore marks were not observed on C1 arms on October 25, 2024, while in attendance at the Center. Over the course of the investigation, sources reported S1 interactions with the infants are “rough”. Interviews revealed S1 pats the children on the back roughly, engages with the infants without supporting their necks and picks up the infants roughly from the toddler table. Sources reported S1 should not work in the infant room of the center. S1 denied treating the infants roughly however confirmed the infants are “horse bounced”. Administrator confirmed concerns have arose regarding S1 interactions with the infants and the Center has put a plan into effect regarding S1. Report continued on page two Report continued from page one Over the course of the investigation, the Department could not determine how or where C1 obtained the marks on and under the arms. However, based on information obtained through records and interviews, S1 did not treat C1 and additional infants in care with dignity when S1 patted the infants roughly on the back, and engaged with the infants without supporting their necks, which is an immediate risk to the children in care. The Center was issued a type A citation for California Code of Regulations, Title 22, Division 12 Chapter 1, Personal Rights. Refer to the attached LIC 809D. On November 8, 2024, LPA reviewed C1 file. Per LPA review, C1 immunizations records showed one immunization was received at the time of enrolment. When questioned about the immunization record, the Administrator did not know why C1s record was not complete and started gathering additional information. The Department followed up with the Administrator on November 20, 2024, and received documentation showing child was on a delayed scheduled. Based on LPAs review of the records, prior to C1s admission in the Center, C1 did not have the required immunizations in accordance with California Code of Regulations, Title 17. A Type B citation is being provided for regulation 101220.1 (a) Immunizations. Refer to LIC 809D. In addition, over the course of the investigation, interviews revealed C1 and C2 were seated at the toddler table with the blankets placed around their waist to assist C1 and C2 with sitting at the table. Interviews revealed C1 and C2 are assisted seaters and do not have the ability to sit up on their own. Administrator confirmed blankets have been placed around the infants while they are seated at the table because they are small and need the extra support. LPA reviewed the manufacturer’s instructions for the toddler table in the classroom. Per review the toddler table “usually” accommodates children 5-24 months of age. Based on Interviews, C1 and C2 were placed to sit at the infant table and needed the extra support of a blanket to assist with sitting up. Therefore, the toddler table was not age appropriate and not the right size to meet C1 and C2 needs. A Type B citation was issued for regulation 101439 (c ) Infant Care Center Fixtures, Furniture, Equipment and Supplies. Refer to LIC 809D LPA Zirbes informed Administrator Lisa Burtner that this report dated November 25, 2024, documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Continued page three Report continued from page two Also, LPA Zirbes informed the facility representative to provide a copy of this licensing report dated November 8, 2024, 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. An exit interview was conducted, and this report and appeal rights were reviewed with Administrator Lisa Burtner.