<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803746
Report Date: 12/11/2025
Date Signed: 12/11/2025 03:52:43 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
07/17/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250717142711
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:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensees, Erik Flatt and Adam Wascow, and Administrator, Matthew RiformoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide a safe environment for residents in care
Staff accepted a resident that needs a higher level of care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensees, Erik Flatt and Adam Wascow, and Administrator Matthew Riformo.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations, “Staff do not provide a safe environment for residents in care and “staff accepted a resident that needs a higher level of care.” Complaint alleged that the facility did not have proper supervision to ensure the safety of residents and staff. Complaint stated that on 07/09/2025 during a facility music activity, Resident 1 (R1) began to have behaviors such as screaming and hitting, and pulling and grabbing at facility staff. Complaint stated that due to R1’s behaviors at the music activity, it resulted in the other residents being left unattended.

Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250717142711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/11/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099

Complaint stated that R1 needed more specialized care than the facility could provide and that the other residents required assistance with activities of daily living such as eating, drinking, toileting and dressing.

Review of R1's care plan indicated that their activities of daily living were similar to the other residents living within the home. R1’s care plan also stated that they have a history of agitation and had a PRN “as needed” medication for their agitation. R1's documentation did not show any prohibited conditions or other conditions that were different from the other residents in the home that would prevent R1 from being unable to reside in a licensed residential home for the elderly. Review of R1’s documents also showed that the facility corresponded with R1’s responsible party and physician regarding medication for their observed behaviors.

Review of facility staff schedule and time sheets showed that on 07/09/2025, the facility had 2 caregivers on-site. Interview conducted with Administrator stated that they are present on-site five times a week to provide additional assistance if needed. Review of 6 of 6 resident care plans showed that none of the residents in the facility required one-on-one supervision or two-person-assistance with their activities of daily living. Review of R1’s documents showed that during R1’s behaviors on 07/09/2025, facility staff acted appropriately and removed R1 from the source of their agitation and administered their as needed medication as prescribed.

Based on document review, interviews, and observations made, these allegations are Unfounded. A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Licensees and Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2