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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701341
Report Date: 12/03/2019
Date Signed: 12/03/2019 04:45:46 PM

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:DEL MAR HIGHLANDS KINDERCARE INFANTFACILITY NUMBER:
376701341
ADMINISTRATOR:KATRINA WANEMACHERFACILITY TYPE:
830
ADDRESS:3808 TOWNSGATE DRIVETELEPHONE:
(858) 794-7710
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:32CENSUS: 27DATE:
12/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Program Specialist Elba LopezTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst, Joelle Redding, made an unannounced visit to follow up on a self reported incident that occurred on 11/27/19 wherein a 5 month old infant (Child #1) was fed a formula bottle instead of his breast milk bottle by accident.

LPA spoke with Staff #1 who was with two infants, Child #1 and Child #2, at the time of the incident. She stated that she stepped in to relieve the prior teacher, Staff #2 who was going home for the day. Staff #2 told her that one of the children was fine but the other need to have his milk at 5:30 p.m. Staff #1 does not recall if Staff #2 mentioned names. Staff #1 says that Child #1's name was on the board as needing the milk. She states she is new to the classroom and isn't completely familiar with the names of the infants yet. Staff #1 stated that she verified with Staff #3 who was next door that the child she was about to feed was Child #1 who's name was on the board. Staff #3 verified that it was Child #1 so she took the only bottle she saw and began to feed it to Child #1. Child #1's mother arrived very shortly thereafter and recognized that the bottle being fed was not her child's and alerted Staff #1 who stated that she then looked at the label and noticed Child #2's name on it.

Ms. Lopez states that school policy is to verify the childl's name with another staff and then verify that information matches what is on the labeled bottle prior to feeding. Red labels are for breast milk bottles and white labels are for formula bottles. Staff #1 did not complete this step causing a formula bottle to be fed to a breast fed infant, Child #1, by mistake.

See LIC 809D for Type B deficiency. Appeal Rights (1/16) were discussed and provided. Signature at the bottom of this report confirms receipt.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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: DEL MAR HIGHLANDS KINDERCARE INFANT
FACILITY NUMBER: 376701341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2019
Section Cited

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Personnel Requirements. Child care center personnel shall be competent to provide the services necessary to meet the individual needs of children in care...This requirement was not met when Staff #1 fed Child #1 the wrong bottle because she did not verify the name on the label. This determination was based upon LPA's interview with Staff #1 and
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Program Specialist Elba Lopez. There were no ill effects, however this is a potential hazard to the health and safety of children in care.
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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: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2019
LIC809 (FAS) - (06/04)
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