Incident investigation·October 9, 2024

On October 9, 2024, at approximately 1:30pm, Licensing Program Analyst (LPA) Maria Olguin-Leon met with Director, Michelle Lee for an unannounced case management visit. LPA explained the purpose of the visit, which was for an unusual incident that occurred on July 24, 2024. Incident was self reported by Director to Regional office. Facility has an infant and preschool program. Incident occurred in infant program. Present in infant room was 4 staff and 11 infants. On date incident occurred, a teacher (T1) in the infant program warmed two breast milk bottles. T1 followed facilities policy regarding warming and feeding infants. Policy is to read out loud and confirm child\342\200\231s name on label, say color code, ounces, and type of milk. When T1 sat down to feed C1, T1 asked T2 to feed C2. T2 was unable to locate C2\342\200\231s bottle and asked T1 where bottle was. T1 checked T1\342\200\231s smock pocket and found the bottle in smock pocket. T1 realized bottle in smock pocket belong to C1 and not C2. T1 realized T1 had mis-fed C1 with C2\342\200\231s bottle. Per Director, Director informed both children\342\200\231s parents and infant did not have any adverse reactions to drinking the wrong breast milk bottle. LPA inspected infant classroom and observed all bottles were appropriately labeled, color coded and dated. LPA observed infants daily schedule of feedings, bottles, and diapering listed on board and reviewed My Bright Day app for daily sleeping schedule and eating schedules. LPA reviewed center's policy regarding bottle feedings and preparation. Per Director, staff was re-trained on policies and procedures regarding infant bottle feedings. Moving forward staff will only handle one bottle at time and continue following facility infant feeding procedures. See LIC809D for deficiency cited against the facility under CCR, Title 22, Div. 12, Ch. 1. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director, Michelle Lee. Appeal rights provided.