425801756-7-20-2022-29-AS-KKOS-CGHMEM-20220720093300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801756
Report Date: 07/19/2022
Date Signed: 07/20/2022 09:34:28 AM

Document Has Been Signed on 07/20/2022 09:34 AM - 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:	TREE OF LIFE RETIREMENT HOMES, INC.		FACILITY NUMBER:	425801756
ADMINISTRATOR:	CHAMILA RUWANPATHIRANA		FACILITY TYPE:	740
ADDRESS:	5364 BERKELEY ROAD		TELEPHONE:	(805) 692-1111
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 4	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Chamila Ruwanpathirana, Administrator		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection and Annual visit to the above-named facility. LPA arrived at 2:34 pm and was greeted by Chamila Ruwanpathirana, Administrator. At the time of arrival, there were 4 residents in care and 3 staff on duty. A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents and one bedridden resident. Currently, there are no residents on hospice. Entrance interview conducted: A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kits were observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There is one fire extinguisher on the premises last serviced on 3/22/2022. There is a total of one carbon monoxide detector and nine smoke alarms throughout the facility all in good working order. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the toxic chemicals are kept in a locked laundry room off the kitchen area of the facility. Medications and sharps are kept in a locked cabinet and drawer in the kitchen area. The backyard has a covered and paved patio with outdoor furniture and a locked shed. The front yard has paved walkways, garden areas and a sitting area. The front and back yards are conducive for outdoor visitations. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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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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: TREE OF LIFE RETIREMENT HOMES, INC.	FACILITY NUMBER: 425801756
	VISIT DATE: 07/19/2022

NARRATIVE

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At 3:08 pm, LPA observed 2 gas cans containing gas, gardening equipment (weed eater, hedge trimmer, lawn blower, and rakes), and a discarded toilet and walker located on the northside of the facility.
Upon arrival at 2:34 pm, the room temperature was measured at 83 degrees Fahrenheit. Hallways, bedroom doors and walls are in good repair. The living room and dining area are neat and clean. LPA advised Administrator that the facility should maintain a comfortable and cool environment at all times.
The facility has five (5) bedrooms for a capacity of six residents. Bedroom #1 has a private bathroom. Bedrooms 2 and 3 utilize a bathroom at the end of the hallway. Access into Bedrooms 5 and 6 is through the facility office with access into the bathroom next to the facility office. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting.
All persons associated with the facility have a criminal background clearance.
At 3:16 pm, LPA observed signage indicating visiting hours to the facility are from 10:00 am – 4:30 pm with a call is requested prior to the visit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report and appeal rights have been issued via email

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2022 09:34 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREE OF LIFE RETIREMENT HOMES, INC.	FACILITY NUMBER: 425801756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview conducted, the licensee did not comply with the section cited above by having gas cans with fuel and hazardous gardening tools located in plain sight at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2022
	Plan of Correction
1 2 3 4	Administrator agrees to remove gardening tools and gasoline cans. Administrator agrees to dispose of discarded items from back yard. Cleared at time of inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/20/2022 09:34 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREE OF LIFE RETIREMENT HOMES, INC.	FACILITY NUMBER: 425801756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(11)

Personal Rights of Residents in all Facilities

(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted, the licensee did not comply with the section cited above by restricting visitors to the facility between 10:00 am and 4:30 pm and requested a call prior to the visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2022
	Plan of Correction
1 2 3 4	Administrator posted new visiting hours to the facility and agrees to contact current residents' families and potential visitors of new visiting hours. Cleared at time of visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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