TREE HOUSE HOLLOW-CREEKSIDE CAMPUS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 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. SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Yang Yang 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)Page: 1 of 2 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 NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 04/02/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 1 2 3 4 5 6 7LPA 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. 8 9 10 11 12 13 14Based 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.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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 LICENSING EVALUATOR NAME:Yang Yang 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 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. SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Yang Yang 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)Page: 1 of 2 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 NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 04/02/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 1 2 3 4 5 6 7LPA 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. 8 9 10 11 12 13 14Based 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.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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 LICENSING EVALUATOR NAME:Yang Yang 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

Type B citation - potential risk if not corrected