425801756-6-4-2024-29-AS-KKOS-D5WTXV-20240604150745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801756
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:08:59 PM

Document Has Been Signed on 06/04/2024 03:08 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:	06/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Chamila Ruwanpathirana, Administrator		TIME COMPLETED:	03:00 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. At the time of arrival, LPA was greeted by one (1) caregiver on duty, and five (5) residents present. Administrator Chamila Ruwanpathirana and Caregiver/Facility 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 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 three 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 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. Facility Manager stated a schedule will be created to keep the patio free of debris. LPA observed fire extinguisher was last serviced on 3/2/2023. Facility Manager stated the extinguisher will be serviced no later than 6/5/2024. 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. 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: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

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: 06/04/2024

NARRATIVE

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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.
Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet.
Residents participate independently in music entertainment, games, baking, and outings to parks, restaurants, religious, and other local attractions.
There are five private bedrooms. Bedroom #1 has a private bath. Bedrooms 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.

The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies by the correction due date may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were 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: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/04/2024 03:08 PM - 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when the fire extinguisher was not current and last serviced on 3/2/2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2024
	Plan of Correction
1 2 3 4	Facility Manager stated the fire extinguisher will be serviced no later than 6/5/2024. Facility Manager will send a photo via email to LPA to confirm the fire extinguisher has been served and is up-to-date.

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: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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