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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006802
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:48:32 PM


Document Has Been Signed on 03/02/2023 04:48 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 10DATE:
03/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Megan Wilson, Executive DirectorTIME COMPLETED:
04:31 PM
NARRATIVE
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On 03/02/2023, Licensing Program Analyst (LPA), Y.Yang made a case management inspection visit and met with the facility's Executive Director Megan Wilson. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucet tested above the allowable level (5.5 ppb) of lead in the water: Sample Site, "A" (located inside the classroom), had a reading of 10ppb. All other sources of water that were tested had a reading below the allowable level of 5.5 ppb.

The facility temporarily removed the faucet from service by turning off the water supply, taping up the sink, and/or by posting a sign by the faucet. The center director notified all staff members regarding the faucet and instructed staff to not use the faucet. Children in care are receiving drinking water from individual tumblers from home and from other drinking water sources located at the center.

The Center Director submitted the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to LPA.

The following deficiency is being cited (see LIC 809D). 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.

Exit interview conducted and report was reviewed with the facility's executive director Megan Wilson.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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Document Has Been Signed on 03/02/2023 04:48 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: TREE HOUSE HOLLOW-CREEKSIDE CAMPUS
FACILITY NUMBER: 493006802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2023
Section Cited

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101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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LPA observed that the facility has temporarily removed the affected faucet “A” from service. The facility plans to either replace the faucet and retest and submit test results to LPA or will permenantly cap the water supply. Results to be sent to yang.yang@dss.ca.gov by 04/02/23.
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Based on a record review, the facility had one faucet (Site “A”) that exceeded the allowable levels of lead in the water. Site A had a reading of 10ppb. This is a potential health and safety risk to 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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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