376700377-12-21-2023-51-CC-GCUS-CYR35V-20231221165722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376700377
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:57:27 PM

Document Has Been Signed on 12/21/2023 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	CENTER FOR CHILDREN & FAMILIES-INFANT AT CAL STATE		FACILITY NUMBER:	376700377
ADMINISTRATOR:	LETISIA FORD		FACILITY TYPE:	830
ADDRESS:	453 LA MOREE ROAD		TELEPHONE:	(760) 750-8750
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	38	CENSUS: 20	DATE:	12/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Letisia Ford		TIME COMPLETED:	05:10 PM

NARRATIVE

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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.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace Curtis	TELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CENTER FOR CHILDREN & FAMILIES-INFANT AT CAL STATE	FACILITY NUMBER: 376700377
	VISIT DATE: 12/21/2023

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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.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace Curtis	TELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CENTER FOR CHILDREN & FAMILIES-INFANT AT CAL STATE	FACILITY NUMBER: 376700377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/12/2024 Section Cited CCR 101226(e)(3)(A)	1 2 3 4 5 6 7	101226(e)(3)(A) Health-Related Services:(e) In centers where the licensee chooses to handle medications: (3) Prescription medications may be administered if all of the following conditions are met:(A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The director states that she will submit a signed and dated letter stating how she will ensure that children's medication is being administered correctly.
	8 9 10 11 12 13 14	Based on interviews conducted by LPA, on 12/18/23 S1 administered the incorrect medication dosage to C1 and did not follow the physician's written instructions. This poses an immediate health, safety or personal rights risk to the children in care.	8 9 10 11 12 13 14	The director also states that she will conduct a meeting with all staff who administer medications to discuss Incidental Medical Services and how medication will be administered and recorded. The director will send LPA a copy of the meeting agenda and staff sign in sheet via email by 01/12/24.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace Curtis	TELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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