493009022-1-7-2021-01-CC-AHON-BX3V4H-20210108150623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 493009022
Report Date: 01/07/2021
Date Signed: 01/07/2021 02:51:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2020 and conducted by Evaluator Jennifer Velasco

COMPLAINT CONTROL NUMBER: 01-CC-20200908093319

FACILITY NAME:	TREE HOUSE HOLLOW-REDWOOD CAMPUS		FACILITY NUMBER:	493009022
ADMINISTRATOR:	PITTS, JAMIE		FACILITY TYPE:	850
ADDRESS:	565 WATERTROUGH ROAD		TELEPHONE:	(707) 787-8026
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	15	CENSUS: 10	DATE:	01/07/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Clare Burns, Megan Wilson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff failed to have an incidental medical service plan in place for day-care child.

INVESTIGATION FINDINGS:

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Due to the COVID-19 public health emergency, an announced tele-visit was conducted with Director Clare Burns (D1) and Executive Director Megan Wilson (M1) by Licensing Program Analyst J. Velasco (LPA) at 2:00 p.m. on 01/07/2021 to deliver the complaint investigation findings. It was alleged staff failed to develop an Incidental Medical Services (IMS) plan for a child (C1) in care; specifically, C1's IMS needs were communicated to facility staff prior to C1's entering care in the facility and no IMS plan was developed by the facility. On 09/15/2020, LPA conducted announced initial complaint investigation inspection via tele-visit due to Covid 19 public health emergency. During that inspection, LPA interviewed two witnesses (M1, D1). During this investigation, LPA obtained and reviewed facility documents, interviewed one adult (A1) on 09/16/2020, 09/17/2020, and 09/21/2020. LPA made multiple attempts to interview other potential witnesses. Documentation and witness statements were observed to provide evidence of attempts by staff to obtain needed information and training to develop the IMS plan; however, documentation and witness statements were also observed to indicate C1 was enrolled and attended the facility without an IMS plan having been developed. Documentation and witness statements corroborate the
Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 01-CC-20200908093319

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TREE HOUSE HOLLOW-REDWOOD CAMPUS	FACILITY NUMBER: 493009022
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/29/2021 Section Cited CCR 101226(e)(3)(B)	1 2 3 4 5 6 7	"For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child." This requirement has not been met as evidenced by witness statements	1 2 3 4 5 6 7	D1 stated they will develop an IMS plan, update the Parent Handbook to include the IMS plan and will ensure staff are trained to comply with IMS requirements prior to enrolling children in the facility. D1 stated they will email IMS Plan of Operation, updated Parent Handbook, training materials,
	8 9 10 11 12 13 14	and documentation that facility got parental permission to administer medication but did not develop an IMS plan to meet C1's needs. This poses a potential risk to children in care.	8 9 10 11 12 13 14	and staff signatures to LPA on or before POC date of 01/29/2021. LPA's email: jennifer.velasco@dss.ca.gov
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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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 01-CC-20200908093319

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TREE HOUSE HOLLOW-REDWOOD CAMPUS	FACILITY NUMBER: 493009022
	VISIT DATE: 01/07/2021

NARRATIVE

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Continued from LIC 9099.
allegation that the facility staff did not develop an IMS plan to meet C1's needs. Based on interviews and facility documents, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. This report was reviewed and discussed with D1 and M1. D1’s original signature was not recorded on this report; however, D1 and M1 were provided with a copy of the LIC9099 Complaint Investigation Report (CIR) and Appeal Rights in an email dated 01/07/2021 and confirmation of read receipt of the CIR is on file.
The following violation of the California Code of Regulation, Title 22, were cited: See attached LIC9099-D.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC9099 (FAS) - (06/04)

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