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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006802
Report Date: 07/08/2019
Date Signed: 07/08/2019 10:09:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:TREE HOUSE HOLLOW-CREEKSIDE CAMPUSFACILITY NUMBER:
493006802
ADMINISTRATOR:WILSON, MEGANFACILITY TYPE:
850
ADDRESS:700 WATERTROUGH ROADTELEPHONE:
(707) 823-1958
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:24CENSUS: 13DATE:
07/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Holly LinkTIME COMPLETED:
10:15 AM
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An inspection was made to the facility by Licensing Program Analyst (LPA) J. Velasco in response to an Unusual Incident Report (UIR) received on 06/21/2019. Facility director Holly Link (D1) reported that an unusual incident occurred between 9:00 and 10:00 a.m. on 06/11/2019, when a child (C1) fell and sustained two hairline wrist fractures. D1 stated that at that time, 14 children were receiving supervision from two staff on the facility playground.

At 8:40 a.m., LPA interviewed D1, who stated C1 was climbing on the hay bale fort built by facility children. The hay bale fort was about four feet high. When C1 had almost reached the top of the fort, they waved their arms and fell, landing on their right arm. Staff comforted C1 and called C1's parents in a timely manner. On 06/12/2019, C1 was taken for medical assessment, and a physician (DR) diagnosed C1 with two hairline wrist fractures. At 9:15 a.m., LPA attempted to interview C1, who did not want to be interviewed. At 9:25 a.m., LPA interviewed S1, whose statements corroborated that staff had provided adequate supervision and contacted parents in a timely manner. D1 stated the facility has assessed the use of hay bales as climbing/building toys, limiting the allowed height of hay bale forts and the locations in which hay bale forts can be built, and will ensure there is additional padding for a well-defined soft fall zone.

During today's inspection, staff were observed to provide adequate supervision and operate within ratio, with 13 children receiving supervision from three staff. This report was reviewed and discussed with D1. All licensing reports are public information and must be made available upon request. No deficiencies were cited during this inspection.
Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2019
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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