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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803746
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:18:46 PM


Document Has Been Signed on 10/19/2022 03:18 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 2FACILITY NUMBER:
216803746
ADMINISTRATOR:FLATT, ERIKFACILITY TYPE:
740
ADDRESS:675 ROSAL WAYTELEPHONE:
(415) 492-1215
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Erik Flatt, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at Three Home Village II for the purpose of conducting an unannounced Required-1 year inspection. LPA was met at the door by carestaff, who performed a Covid-19 test on LPA and granted LPA access into the home. Testing is done prior to entrance for all visitors as a precaution.

LPA toured the facility with licensee, Erik Flatt. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. 3 Fire Extinguishers were found to be last charged on 9/1/2022. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 105 and 110 degrees F. The facility tests the water each day for variations in temperature. 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. 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. The outdoors of the facility provided attractive and easily accessible garden and visiting areas for residents and their visitors, which is especially beneficial for social distancing.

Facility has PPE supply stored in the storage sheds in back yard. Staff have had all PPE training required. Facility is N95 Fit tested. Disaster drills were conducted on 9/16/2022Covid-19 Mitigation Plan and Infection Control Plan were submitted.
No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted with Licensee, Erik Flatt.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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