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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803746
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:26:18 PM

Document Has Been Signed on 11/15/2024 03:26 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:THREE HOME VILLAGE 2FACILITY NUMBER:
216803746
ADMINISTRATOR/
DIRECTOR:
FLATT, ERIKFACILITY TYPE:
740
ADDRESS:675 ROSAL WAYTELEPHONE:
(415) 492-1215
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Licensee/Administrator, Erik Flatt and Adam Waskow, and Administrator, Matthew Riformo TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 11:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Erik Flatt and Adam Waskow, and Administrator, Matthew Riformo Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 6 non-ambulatory residents and 2 bedridden residents for a total capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 4 Residents in care and 2 staff members on-site.

LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 1 staff room, 3 bathrooms, and common spaces. Facility has an office space located in the backyard. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected August 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted November 2024.

LPA reviewed staff files, resident files, and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. Administrator's Certificates for Erik Flatt (7005115740), Adam Waskow (7014460740), and Matthew Riformo (7013848740) were current with expiration dates of 06/28/2026, 01/16/2026, and 02/15/2025.

Continued on LIC809C

Victoria BertozziTELEPHONE: (707) 588-5059
Caitlynn FeliasTELEPHONE: 707-588-5039
DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: THREE HOME VILLAGE 2
FACILITY NUMBER: 216803746
VISIT DATE: 11/15/2024
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Continued from LIC809

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 12/15/2024.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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