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On November 21, 2025, the Office of Childhood received an allegation that last year, in September 2024, Child A (2-years-old) was given the wrong breastmilk. After completing an investigation, Compliance Inspector (CI) Jackie Ruth, found this allegation to be substantiated based on the following rule violation:
5 CSR 25-500.202(2)(B) which states, "The written diet plan for each infant/toddler shall be followed. The parent(s) shall update the plan according to the individual needs of the child until they grant permission in writing for the child to eat table foods."
On December 3, 2025, CI Ruth conducted an unannounced inspection of the facility and held in person interviews with Emily Page, Karrie Left Hand, and Nadia Benmoussa. All staff interviewed admitted that this incident occurred. Nadia said that she fed Child A the wrong bottle. She said there were two similar bottles next to each other, she grabbed the wrong one, and Child A drank approximately 1-2 ounces of the breastmilk. She told the director right away and called the parents involved. Emily, Karrie, and Nadia all explained that they communicated thoroughly with Parent A about the situation. Karrie and Nadia explained the corrective measures that were put in place after this mistake happened.
On December 3, 2025, CI Ruth conducted an unannounced inspection of the facility and observed Child A's infant and toddler feeding and care plan. The plan indicated that Child A was to receive formula at 9:00 a.m. and 12:00 p.m., and infant food at 9:00 a.m., 12:00 p.m., and 3:00 p.m. The plan also indicated that Child A shall receive Enfamil Gentlease formula provided by the parent(s).
On December 3, 2025, CI Ruth observed the facility's method for storing, heating, and serving bottles to infants. CI Ruth observed each child's bottle was kept in the refrigerator in an individually labeled bin with the child's name, and each individual bottle was also labeled with that child's name. The same process was observed for breastmilk storage in the freezer. Two separate bottle warmers were observed, one of which was labeled for breastmilk. CI Ruth observed the "coaster system" the facility has implemented. Each child was observed to have a laminated tag with the child's name and picture, and a line to write when the bottle will expire.
On December 4, 2025, CI Ruth conducted an interview with Parent A via phone. She said that when Child A was in the infant classroom, they mistakenly gave Child A another child's breastmilk. She was concerned about the health of the other mother and how it could affect Child A. She said she talked to the teacher who fed the wrong bottle, and the teacher felt badly, realized her mistake, and said she would try her best to not let it happen again. Parent A said she did not receive a formal report of what the facility would do to make sure this did not happen again.
On December 4, 2025, CI Ruth requested and observed Child A's medical exam form because the incorrect date of birth is displayed on Child A's enrollment form and Child A's infant feeding care plan. Parent A confirmed that Child A's date of birth is September 19, 2023, which is reflected on the medical exam form. The other forms showed Child A's date of birth as September 19, 2024.
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