216803745-11-21-2023-21-AS-DTOA-CXT2QD-20231121163546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803745
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:35:50 PM

Document Has Been Signed on 11/21/2023 04:35 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	THREE HOME VILLAGE I		FACILITY NUMBER:	216803745
ADMINISTRATOR:	WASKOW, ADAM		FACILITY TYPE:	740
ADDRESS:	665 ROSAL WAY		TELEPHONE:	(415) 492-1213
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:58 AM
MET WITH:	Adam Waskow, Administrator		TIME COMPLETED:	01:00 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	On 11/21/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrators, Adam Waskow & Matthew Riformo. The facility is a one story building licensed for 6 non-ambulatory and 2 bedridden residents, along with a hospice waiver capacity of 3. The facility currently provides care for 6 residents, 1 of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrators, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 9/29/2023 at the time of visit. Smoke and carbon monoxide detectors found throughout the facility were interconnected, and found to be in working order. Additional carbon monoxide detectors were also tested and functioning. Auditory alarms at all exits for residents with dementia were tested and fully functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food replenished once per week. Food stored in the kitchen and separate food storage in the backyard were properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions listed in each resident's file. Toxins are stored in supply closets and under kitchen sinks throughout the facility all of which were found to be secured. There was a supply of PPE, hygiene, continence care and paper products available for residents. All resident’s rooms have lighting & appropriate furnishing and found to be in clean and safe condition. Water was measured at faucets accessible to residents and measured at 112.8 degrees F which is within regulation. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: THREE HOME VILLAGE I	FACILITY NUMBER: 216803745
	VISIT DATE: 11/21/2023

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Medications were located in designated kitchen cabinets and found to be secured. LPA conducted a spot check of medications and found all administering and records including centrally stored medication records and medication administration records to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private bedrooms, visited by family members or in the outdoor patio spaces for leisure. Residents are visited by family frequently and interact with one another in the dinning area, common spaces as well as in resident private rooms.

LPA conducted a sample file review for staff and found staff to have 1st Aid & CPR training certification up to date and on file. All staff have completed annual and initial on-boarding training requirements and are on file. All staff have also been properly associated to the facility and confirmed on the Guardian System roster. Upon a spot review of resident files, LPA found residents to have all current required documentation on file including Service Plans and Physician's Reports. LPA and Administrator discuss the appropriate dimensions for Complaint Poster PUB475 and to provide updated photo corrections to CCLD. Technical Advisory issued.

Administrator, Adam Waskow's Administrator Certification 6017406740 is currently active through 1/16/2024.

LPA requested the following documents be sent to CCL by COB 12/21/2023:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

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