Incident investigation·December 21, 2023

On December 21, 2023 at 2:00 p.m. Licensing Program Analyst (LPA), Leilani Curtis conducted an unannounced inspection to follow up on a self-reported incident that occurred on 12/18/23, wherein a staff member (S1) administered the incorrect dosage of medication from an Albuteral Inhaler to a child (C1). Upon arrival LPA met with Director Letisia Ford and proceeded to tour the facility. There were 20 children present with 10 staff members. Appropriate ratio/capacity was observed. Staff members have the required background clearances and are associated to the facility. LPA interviewed staff #1 (S1), staff #2 (S2) and the parent (P1) of the child involved. On 12/18/23 at approximately 11:00 a.m., S1 administered an incorrect medication dosage to C1. S1 states that due to a misunderstanding/miscommunication with P1 the physician’s instructions on how much medication to be administered were not followed. As a result of the increased medication dosage C1 developed an increased heart rate. The parent of C1 was notified and C1 was taken to a nearby hospital for treatment. C1 returned to care the same day. The parent was given an incident report the same day. LPA inspected the Albuteral Inhaler and reviewed medical documentation. The director states that after the incident a meeting was held with all staff who administer medication. All staff were advised that they must follow the doctor’s instructions and not deviate from those instructions. LPA provided the director with a copy of PIN 22-02-CCP (Best Practices Related to the Provision of Incidental Medical Services). The director will send LPA a copy of the facility's Incidental Medical Services Plan of Operation by 1/12/24. The facility reported the incident to Community Care Licensing timely. See LIC809D for cited deficiency. LPA Curtis informed Director Ford that this report dated 12/21/23 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care. Also, LPA Curtis informed Director Ford to provide a copy of this licensing report dated 12/21/23 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 Director Ford. A notice of site visit was given and must remain posted for 30 days.