216803746-4-14-2023-21-AS-KMOA-CR3TK3-20230420144716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803746
Report Date: 04/14/2023
Date Signed: 04/14/2023 10:53:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230112144348

FACILITY NAME:	THREE HOME VILLAGE 2		FACILITY NUMBER:	216803746
ADMINISTRATOR:	FLATT, ERIK		FACILITY TYPE:	740
ADDRESS:	675 ROSAL WAY		TELEPHONE:	(415) 492-1215
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Adam Waskow		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Facility lacks adequate staffing to meet resident's needs
Staff are not bathing resident
Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, Adam Waskow.

During the course of the Investigation, Licensing Program Analyst (LPA) Felias reviewed and requested documents, conducted interviews, and made observations.

There is an allegation that the Facility lacks adequate staffing to meet resident’s needs. The Reporting Party (RP) reported that the facility had a lack of staff during the months of December 2022 and January 2023 due to several staff members going out of the country for a vacation. Staff interviews conducted stated that during December 2022 and January 2023 there were always two staff members on shift at a time and that many of them had agreed to work overtime to allow for the other staff members to go on vacation.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230112144348

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2	FACILITY NUMBER: 216803746
	VISIT DATE: 04/14/2023

NARRATIVE

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Continued from LIC9099

Interviews also indicated that the Administrators were available at any time and assisted care staff as needed. Time Sheet Records and Facility Staff Schedules indicated that there were at least two caregivers on shift at a time for the months of December 2022 and January 2023. Based on interviews conducted and records reviewed, this allegation is UNSUBSTANTIATED.

There is an allegation that staff are not bathing resident. RP reported that Resident 1 (R1) was observed to have unclean hair by their Responsible Party. Attempts to obtain more information from R1’s Responsible Party were unsuccessful. Records reviewed showed that R1 was given either a shower or a sponge bath consistently every week throughout the months of December 2022 and January 2023. Based on records reviewed, this allegation is UNSUBSTANTIATED.

There is an allegation that staff mismanaged resident’s medication. RP reported that R1 had been prescribed a medication patch that was to be administered every 12 hours. RP reported that R1’s Responsible Party observed the medication patch to not be on the resident. Attempts to obtain more information from R1’s Responsible Party were unsuccessful. Review of R1’s Medication Administration Record (MAR) stated that R1 has a prescribed medication patch to be applied every 8 hours and showed that the medication patch had been administered appropriately. Staff Interviews conducted stated that residents with medication patches have them applied in the morning and taken off in the evening. During visit conducted on 04/14/2023, LPA observed a medication patch on R1’s neck. Based on records reviewed, interviews conducted, and observations made, this allegation is UNSUBSTANTIATED.

A finding that the Complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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