Incident investigation·January 6, 2023

On 1/6/2023 at 10:15am, Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection to follow up on a self reported incident report. Upon arrival, LPA Williamson met with Rosa Johnson, Assistant Director. LPA discussed the purpose of the inspection and proceeded to tour the facility. There were five (5) infants in Room 301 with two (2) staff, eight (8) infants in Room 306 with two (2) staff. LPA observed nine (9) infants and three (3) staff from Room 316 entering the building and returning from a walk. The facility operates Monday \342\200\223 Friday 7:00am \342\200\223 5:30pm. Director Jacqueline Serrano arrived during the inspection. On 12/19/2022, the director self reported an incident of a possible personal rights violation that allegedly occurred on 12/13/2022. On 12/13/2022, Staff 1(S1) and Staff 2 (S2) were providing bottle feedings for the infants in room 301 between 8:00 am and 8:32 am. S1 put the breast milk bottle for Child 1 (C1 ) into the bottle warmer and while waiting continued to assist other infants who were in the highchairs with their feedings. S2 who was assisting in the classroom, picked up Child 2 (C2) for their feeding, reaching into the bottle warmer to retrieve a breast milk bottle. S2 proceeded with the feeding, and fed C2 approximately three ounces of breast milk that belonged to C1. Staff 3 (S3) reported to the classroom to relieve S1 for a break. S1 reviewed the infant board and determined that C1 was due for a feeding. S3 went to the refrigerator and noticed that C1's breast milk bottle labeled #1 was missing. S3 advised S2 to stop feeding C2 and observed that there was one ounce remaining in the bottle. S3 observed that the rubber label that was initially attached to C1's breast milk bottle which included C1's name and the date was at the bottom of the warmer. This resulted in C2 being fed the breast milk bottle belonging to C1. The parents of C1 and C2 were notified immediately and there was no medical attention required. Interviews were conducted with the director, assistant director, staff and daycare parents. Based on evidence obtained, it was determined that the facility staff violated the personal rights of C2. Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited, see LIC809 D. Per Director, an investigation was conducted and S1 was reprimanded. Director has conducted training with staff and implemented bottle feeding procedures in the infant classrooms. A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. LPA observed the Director post the Notice of Site Visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted with Director Jacqueline Serrano. Licensee/Appeal Rights (LIC9058) along with a copy of this report was provided to Director and their signature on this form confirms receipt of these rights.