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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803746
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:30:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:THREE HOME VILLAGE 2FACILITY NUMBER:
216803746
ADMINISTRATOR:FLATT, ERIKFACILITY TYPE:
740
ADDRESS:675 ROSAL WAYTELEPHONE:
(415) 492-1215
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 5DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensee, Erik FlattTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Three Home Village II for the purpose of conducting an unannounced Required-1 year inspection. LPA was met at the door by Licensee, Erik Flatt and granted access into the home.

LPA toured the facility with licensee. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher was found to be last charged on 9/2020 at the time of the visit with the next charge date being by the end of the month. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 116 degrees F following of Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored under kitchen sink cabinet and small living room closet. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required. Facility is N95 Fit tested on September 8, 2021. Disaster drills were conducted in May 2021. No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Licensee, Erik Flatt.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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