Incident investigation·March 7, 2025

On 3/7/25 at 9:30 AM, Licensing Program Analysts (LPAs) Keturah Lane & Hanna Lucas conducted an unannounced case management visit to follow up on an incident that happened on 2/20/25 and was reported to the duty line the same day. The written report was received from the facility on 2/26/25. The incident involved an infant (C1) that received the wrong bottle that was labeled for another child (C2). Upon arrival, LPAs met with Director Amanda "Mandy" Hernandez and toured the facility. LPAs observed a total of 28 infants/toddlers with the following ratios: Infant A (1) - had 7 infants with staff members Areli Torres and Socorro Cervantes Infant B (2) - had 8 infants with staff members Maritza Rosas and Melody Diaz Infant C (3) had 9 toddlers with staff members Ariana Garcia, Morgan Hodges and Miriam Escobar Toddler A had 4 toddlers with staff member Katherine Ryan Toddler B classroom was not in use All staff were fingerprint cleared and associated to the facility. During this visit, LPAs reviewed staff records for S2, received an updated LIC500, LIC9040 and documents related to the incident. LPAs also interviewed staff member (S1) and Director. Staff member (S2) was not coming into the office until later in the day. Director stated that she retrained both S1 and S2 regarding bottle feeding. S1 stated that there was a miscommunication regarding whose bottle was in the warmer and the protocol of naming the label aloud to second staff member ("second staff bottle verification") was not followed. Parents of C1 and C2 were both notified of the incident. Director stated she would retrain all staff (both infant and preschool licenses) regarding bottle feeding procedures and protocols on 3/20/25. Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D). Exit interview conducted and report was reviewed with Director Amanda Hernandez. Notice of site visit was provided and must remain posted for 30 days.