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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801756
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:42:56 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2024 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20240605132235
FACILITY NAME:TREE OF LIFE RETIREMENT HOMES, INC.FACILITY NUMBER:
425801756
ADMINISTRATOR:CHAMILA RUWANPATHIRANAFACILITY TYPE:
740
ADDRESS:5364 BERKELEY ROADTELEPHONE:
(805) 692-1111
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chamila Ruwanpathirana, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not provide timely medical care to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Administrator Chamila Ruwanpathirana and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 6/12/2024 from 9:40 am to 1:40 pm. LPA toured the facility, conducted interviews with staff and residents, and obtained documents.
On the allegation: Staff did not provide timely medical care to resident. It was alleged that a resident fell out of bed during the night, but staff did not respond until the next morning.
Facility manager stated Resident 1 (R1) fell out of bed, even though they had a half rail. They believe R1 scooted down around the rail, took a few steps then fell. The night staff heard the fall and called the manager and administrator immediately. The night staff assisted R1 back to bed and checked on them. R1’s arm was swollen, and they called 9-1-1 at that time as well as R1’s responsible party. R1 was put in a soft cast and returned to the facility.

Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240605132235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2024
NARRATIVE
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Staff stated while passing morning medications, they found R1 on the ground. They assisted R1 back to bed, and R1 did not indicate any pain. Staff indicates they found R1 around 6:30 am to 7:00 am. Around 7:30 am or 7:40 am, staff checked on R1 and saw the arm was swollen and they believed it to be broken. Staff called the administrator. Administrator stated she arrived at the facility around 7:30 am or 8:00 am. Administrator called hospice first, stating “we are not supposed to call 9-1-1 if they are on hospice.” The hospice nurse came and 9-1-1 was called.
R1 also experienced another fall from a chair. Manager stated the pad on the chair slipped out and R1 slid forward, and it happened very quickly. R1 hit their head on the floor and 9-1-1 was called. R1 received stitches and returned to the facility. Administrator stated they called hospice, and hospice indicated to call 9-1-1. Administrator stated again this is the procedure when a resident is on hospice.
For medical emergencies that are not directly related to a resident’s terminal illness and reason for hospice services, the licensee must call 9-1-1 and seek medical attention for the resident. Based on the information obtained, R1 received untimely medical attention on two occasions, as evidenced by the delay to contact the administrator and/or hospice before calling 9-1-1. Therefore, the allegation is deemed Substantiated at this time.

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



Exit interview conducted. Due to technical difficulties, report and Appeal Rights were emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240605132235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
87469(c)(3)
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87469(c)(3) Advanced Directives. Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
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Administrator agrees to submit a signed statement of understanding of 87469. Administrator agrees to review CCR 87649 in its entirety with facility staff.
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This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above when they did not seek immediate emergency medical assistance for R1, which posed an immediate health and safety risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2024 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20240605132235

FACILITY NAME:TREE OF LIFE RETIREMENT HOMES, INC.FACILITY NUMBER:
425801756
ADMINISTRATOR:CHAMILA RUWANPATHIRANAFACILITY TYPE:
740
ADDRESS:5364 BERKELEY ROADTELEPHONE:
(805) 692-1111
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Chamila Ruwanpathirana, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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2
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9
Staff are intoxicated while working at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Administrator Chamila Ruwanpathirana and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 6/12/2024 from 9:40 am to 1:40 pm. LPA toured the facility, conducted interviews with staff and residents, and obtained documents.
On the allegation: Staff are intoxicated while working at the facility. It was alleged that staff consumed alcohol while on shift. It was also alleged staff offered a resident alcohol. Facility manager and administrator both stated staff do not drink alcoholic beverages on the property. Manager and administrator both stated no residents drink alcohol, and they would never offer anyone alcohol. Manager indicated one resident became sober and must not have any alcohol on the premises. Staff interviewed also stated they have never seen

Please continue to 9099-C, Pg 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240605132235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2024
NARRATIVE
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staff or residents drinking alcohol in the facility. Residents interviewed stated they have never seen staff drinking, and never smelled alcohol. Residents also stated they had never been offered alcohol.

Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Due to technical difficulties, report and Appeal Rights were emailed to Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5