Incident investigation·March 3, 2026

An unannounced case management inspection was conducted today 3/3/26 at 12:42pm by Licensing Program Analyst (LPA), Tammy Dutra . LPA met with the Director Jennifer Duren in response to two Unusual Incident Reports received by the Department on 2/13/26 and 3/2/26. It was reported that on 2/4/26 a child in care, (C1) fell off a chair and hit their head on the pavement on the playground. It was also reported that C1 had a second incident where they were playing on a hop along ball and fell on a rock causing a bump between their eyes. Child was taken to the emergency room for a concussion after the first injury and a physician following the second injury. The Director was interviewed on 3/3/26 at 12:45pm and stated that on 2/4/26 C1 was standing on a chair and another child pulled the chair out from underneath them. C1 fell back and hit their head on the concrete . Director stated first aid was administered and child's representative was called. C1 was picked up from the center and taken to receive medical care. Director stated they were unaware that C1 was taken to the emergency room and was informed later by the lead teacher. There were approximately 18 children with five teachers during the first incident. The first incident was reported to Community Care Licensing on 2/13/26. Director stated that another incident occurred on 2/26/26 when C1 was bouncing on a hop along ball and fell forward landing on rocks. Director stated that C1 was taken to their pediatrician and it was determined the wound was superficial and there was no suspected concussion. Director stated during the second incident, there were approximately 12 toddlers with three teachers on the playground. Three teachers were interviewed on 3/3/26 and none of the teachers witnessed C1 fall on the first or the second incident. All teachers stated they were focused on other children and did not see C1 fall. After the teachers interviewed nearby children they believe that C1 was pushed off a chair by another child during the first incident. None of the teachers saw C1 fall off the hop along ball and when C1 shared they were hurt, none saw a visible injury. One staff, S3 stated they recognized a mark on C1 approximately 1-2 hours following the incident and notified C1's representative upon discovery of the mark. All teachers stated they were operating in a four children to one teacher ratio during both incidents. All teachers felt the injury could have been prevented if the child was observed standing on a chair and away from the concrete on the basketball court. Two teachers present during the second incident felt the injury could have been prevented if C1 had not been given access to the hop along ball as they believed it was not age appropriate. C1 was described as active and adventurous. During today’s inspection, the facility was toured. LPA took photos of the chair, basketball concrete, the hop along ball and the rocks where C1 fell. LPA reviewed staffing ratio and children ratio during the two incidents including the ouch reports that were shared with C1's representative. LPA photographed the updated zoning charts staff are being asked to use to ensure active supervision is taking place on the playground. LPA observed children playing on the playground and staff stationed in various places. Based on interviews, record review and observation it was determined there was a lack of supervision, inappropriate equipment being used for children in care and a failure to report an injury in a timely manner. LPA determined two injuries could have been prevented if visual supervision were being followed and appropriate equipment were being used. The following deficiencies are being cited on the LIC809-D: CCR 101239(m), CCR 101229(a)(1) and CCR 101212(d)(B). LPA Tammy Dutra informed facility representative Jennifer Duren that this report dated 3/3/26 documents two Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. LPA Tammy Dutra informed the facility representative to provide a copy of this licensing report dated 3/3/26 that documents any Type A citations 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 the facility representative Jennifer Duren. Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.