425801756-5-23-2023-29-AS-KKOS-CS4VXH-20230523164934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801756
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:50:16 PM

Document Has Been Signed on 05/23/2023 04:50 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:	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: 5	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	CHAMILA RUWANPATHIRANA, ADMINISTRATOR		TIME COMPLETED:	05:10 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 Annual Required visit and inspection of the facility. LPA arrived at 11:58 am and was greeted by one (1) caregiver on duty, and five (5) residents present. Administrator Chamila Ruwanpathirana and Caregiver/Office Manager, Fred DeLorenzo were present. LPA informed Administrator of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility has accepts residents with a dementia diagnosis; has a waiver for three hospice residents; and a fire clearance for six non-ambulatory residents and one bedridden resident. Currently, there are two residents on hospice and there is one resident who is bedridden residing in the facility. There are currently five (5) residents residing in the facility. 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, mandatory reporter, and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The inside of the facility was seen to be in good repair. The backyard has a patio table with chairs and an umbrella. Fire inspection was current as of 3/2/2023. The kitchen area was sufficiently stocked with two-day perishables and non-perishables for seven days. Snacks and beverages are available. Sharps are kept in a locked drawer located in the kitchen island. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. 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: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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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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: 05/23/2023

NARRATIVE

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Residents participate independently in music entertainment, games, baking, and outings to parks, restaurants, religious, and other local attractions.
The front yard consists of a walkway, sitting area, and a lawn and garden area. The backyard consists of a large, concrete surface with a sitting area with one table and chairs. The front yard and backyard are conducive to visitations with family and friends. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The washer, dryer, and cleaning supplies are kept in a locked laundry room and is inaccessible to residents in care
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
There are five private bedrooms. Bedroom #1 has a private bath. Bedroooms 2, 3, and 4 have a bathroom off the hallway shared by all residents. Bedrooms #5 and 6 have a shared bathroom off the hallway. The bathrooms have secure grab bars and no skid flooring.
Each bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. .
All persons associated with the facility have criminal record clearance. Administrator certificate is valid.
Records reviewed indicate all personnel and residents' records are current and up-to-date.

Exit interview conducted. A copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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