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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703672
Report Date: 08/06/2024
Date Signed: 08/15/2024 04:43:19 PM

Document Has Been Signed on 08/15/2024 04:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TUMBLEWEED GUEST HOMEFACILITY NUMBER:
421703672
ADMINISTRATOR/
DIRECTOR:		WASANTHA MOHOTTIGEFACILITY TYPE:
735
ADDRESS:5022 VIA JACINTOTELEPHONE:
(805) 964-2806
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 4CENSUS: 3DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Wasantha Mohottige, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Tracy Jackson, Lead Quality Assurance Specialist (LQAS), Tri-Counties Regional Center (TCRC) accompanied LPA in the inspection. At the time of arrival, there were two residents in care and one staff member on duty. Administrator Wasantha Mohottige was present in the facility. One resident was out of the facility attending a day program.
LPA explained the purpose of the visit. The facility is a one-story home licensed as an Adult Residential Facility (ARF) for residents with a developmental disability and contracts with Tri-Counties Regional Center.
LQAS and LPA toured facility with Administrator.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. A fire extinguisher is located in the kitchen area near the stove. The expiration on the extinguisher is 7/20/2035.
At approximately 10:29 am, Administrator, LQAS, and LPA observed the window screen in Bedroom 3 was pushed out of its frame and has a hole toward the top left corner of the screen. At approximately 10:33 am, Staff revealed burnt cigarette butts burned into the bathroom matt of the hallway bathroom.
LQAS and LPA observed four private bedrooms for the three residents residing in the facility.
The facility has 4 private bedrooms; Bedroom 4 has a private bathroom. The facility has a garage conversion for live-in staff quarters. The laundry room connects the staff quarters to the home.
Walls, floors, doors, and doorways are clean with no safety hazards. Hallways, bedroom doors and walls are in good repair. The kitchen area consists of a countertop area, a refrigerator, a stove, a microwave, and a sink. Sharps are kept in a locked drawer with no access to residents.
There is a sufficient amount of non-perishables for seven (7) days and perishables for two (2) days. The living room and dining area are in good condition. The facility maintains a comfortable temperature.

Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TUMBLEWEED GUEST HOME
FACILITY NUMBER: 421703672
VISIT DATE: 08/06/2024
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 First aid kit was observed to be complete. Centrally stored medications are kept in a locked cabinet in the family room. Five (5) smoke alarms and 1 carbon monoxide alarm were measured and in good working order.
The backyard consists of a covered patio and a picnic table. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
Residents' records were reviewed. LPA noted Physician's reports, Admission Agreements, Pre-Appraisals, Appraisals/Needs and Services, and Health screenings are current.
Staff records were reviewed. LPA noted current First Aid training, fingerprint clearances, criminal background, education and training verification, health screenings, employee rights, and TB test documentation in each staff member's file.

The following deficiencies observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2024 04:43 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 08/06/2024 at 12:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TUMBLEWEED GUEST HOME
FACILITY NUMBER: 421703672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(b)
80087(b) Buildings and Grounds: All clients shall be protected against hazards within the facility through provision of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted, , the licensee did not comply with the section cited above when burnt cigarette butts were found in the hallway bathroom and a cigarette butt was found in the bedroom drawer of Bedroom 3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee agrees to monitor Resident 3 more closely, create a non-smoking in the facility contract with R3, and will submit the contract to TCRC and CCLD.
Type A
Section Cited
CCR
80088(b)
80088(b) Furniture, Fixtures, Equipment, and Supplies: All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted the licensee did not comply with the section cited above when the window screen in Bedroom 3 was observed to be torn and pushed out of the window frame which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee agrees to replace the screen in Bedroom 3 and will train staff to document repairs needed during routine cleanings.
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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


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