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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803747
Report Date: 11/14/2022
Date Signed: 11/14/2022 12:52:38 PM


Document Has Been Signed on 11/14/2022 12:52 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 3FACILITY NUMBER:
216803747
ADMINISTRATOR:FLATT, ERIKFACILITY TYPE:
740
ADDRESS:679 ROSAL WAYTELEPHONE:
(415) 492-1220
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 5DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH: Administrator, Nina Gibson, and Licensee, Adam WaskowTIME COMPLETED:
01:15 PM
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At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit Inspection and met with Administrator, Nina Gibson, and Licensee, Adam Waskow. Facility currently has 5 residents, and serves residents with dementia. Facility has a plan of operation for dementia care and programming. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire and also had an antigen Covid-19 test conducted. Antigen testing is done prior to entrance for all visitors as a precaution.
LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms.

LPA and Administrator discussed the following: booster shots, activities, staffing, N95 fit testing, and training. Facility has a plan in place if a staffing shortage were to occur. Facility submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL).

Fire extinguishers was last serviced September 2022. Facility has Nest Smoke and carbon monoxide detectors which were shown to be operational. The last facility fire and evacuation drill was conducted September 2022.

Continued on LIC-809 C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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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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 3
FACILITY NUMBER: 216803747
VISIT DATE: 11/14/2022
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Continued from LIC-809

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Liability Insurance

Documents to be submitted to CCL by due date of Friday, December 9, 2022.

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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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