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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803746
Report Date: 01/29/2026
Date Signed: 01/29/2026 02:58:18 PM

Substantiated


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
09/08/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250908113646
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:
01/29/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensees, Erik Flatt and Adam Waskow, and Administrator, Matthew RiformoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not administer medications as prescribed
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensees, Erik Flatt and Adam Waskow, and Administrator, Matthew Riformo.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not administer medications as prescribed.” Complaint alleged the following: facility staff were documenting that Resident 1’s (R1’s) lubricating eyedrops was given, but were not administering it during the evening, that they ran out of R1’s estradiol cream, and that R1 was given their Fosfomycin Tromethamine medication every 48 hours when the physician order stated that the medication was to be given every 72 hours. Complainant stated that R1 did not receive their eyedrops in September and October 2024, and that R1’s estradiol cream was running low in November 2024.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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 8
Control Number 21-AS-20250908113646
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: 01/29/2026
NARRATIVE
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Continued from LIC9099

Review of R1’s medication administration record for Dorzolamide-Timiolol, Latanoprost, and Erythromycin eyedrops in September and October 2024 showed that R1 received their eyedrops. Review of R1’s medication administration record for November and December 2024 indicated that facility had estradiol cream available and administered it appropriately. LPA is unable to review R1’s eyedrops or estradiol cream as it is no longer available. Interview conducted with the licensees stated that the facility was not allowed to communicate with R1's Primary Care Physician or medical professionals at all and that all communication with medical was done through R1’s responsible party.

Review of R1’s physician orders for Fosfomycin Tromethamine stated “Take 1 packet by mouth every 72 hours.” Review of R1’s medication administration record showed that R1 received this medication on 10/24/2023, 10/26/2023, and 10/28/2023.

Based on record review and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.

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

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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
09/08/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250908113646

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:
01/29/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensees, Erik Flatt and Adam Waskow, and Administrator, Matthew RiformoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are not following resident care plan
Staff do not have proper training
Facility did not ensure maintenance of resident’s personal care equipment
Facility does not have enough staff for resident care needs
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensees, Erik Flatt and Adam Waskow, and Administrator, Matthew Riformo.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff are not following resident care plan, staff do not have proper training, facility did not ensure maintenance of resident’s personal care equipment, and facility does not have enough staff for resident care needs.”

“Staff are not following resident care plan” – Complaint alleged that the facility was not following R1’s dietary requirements, that R1 was not being changed enough, and that R1 was not having their teeth brushed.Complaint reported that facility staff did not follow R1’s dietary requirements or aspiration protocols.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 21-AS-20250908113646
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: 01/29/2026
NARRATIVE
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Continued from LIC9099

Complaint stated that R1 was observed with smoothie remnants on their pillow indicating that facility staff did not ensure that R1’s mouth was clear of food before putting them to bed. Complaint also stated that facility staff were not using thickened water for R1 when brushing their teeth. Review of R1’s Physician’s Report dated 07/28/2024 stated that R1 was to be on a mechanical soft diet that was vegan and low sugar. Interview conducted with Licensees and Administrator stated that the facility did not prepare food for R1 because R1’s family would bring in their meals. Interviews conducted with facility staff and witnesses revealed conflicting statements. 8 of 8 interviews conducted stated that R1’s family prepared and brought in the meals for R1 to eat. Per interviews conducted, these meals consisted of pureed food, soups, smoothies, and thickened water. 5 of 5 staff interviews stated that R1 would be fed by family or by their one-on-one caregiver. 2 of 3 witness interviews stated that R1 was fed by family or by their private caregivers, while 1 of 3 witness interviews stated that facility staff members would help feed R1 when R1’s family was unable to feed R1 themselves. 1 of 3 witness interviews also revealed that the only time they observed facility staff with R1 at mealtime was to give them their medications. 5 of 5 facility staff interviews were able to describe what to do if a resident were to aspirate. Review of R1’s documents showed that on 05/27/2023, R1 had a swallowing evaluation conducted where it was determined that R1 did not have any overt signs or symptoms of aspiration during eating or drinking. Evaluation continued to state that R1’s diet was to continue to be regular, with liquid viscosity to be nectar thick at the family’s preference, while R1 may have thin water between meals.

Complaint reported that facility staff were not changing or repositioning R1 enough causing R1’s pressure injury to worsen. Review of facility records showed that R1’s physician sent orders on 06/06/2025 stating “when in bed, please reposition every 1 hour. For night, please reposition every 1-2 hours while in bed.” Review of facility documents showed that on 06/06/2025, facility implemented their repositioning log. Review of R1’s repositioning log for June and July 2025 indicated that R1 was checked at least every 2 hours and documented if R1 was on their left or right side, did a skin check for redness or moisture, and noted any additional concerns such as if R1 was dry or not. Additional documentation also showed that facility had a bowel movement log for R1 in May, June, and July 2025. 8 of 8 interviews conducted stated that R1 would be changed at least two to three times a day or more if needed.

Complaint reported that facility staff were not brushing R1’s teeth. Complainant provided photos to Department. Per Complainant, photos provided are of R1’s dry toothbrush which indicated the facility was not brushing R1’s teeth. Interviews conducted with facility staff and witnesses revealed conflicting statements. 5 of 5 staff interviews stated that they brush R1’s teeth twice a day, once in the morning and once in the evening. 1 of 3 witnesses stated that they only saw facility staff brush R1’s teeth in the morning. 1 of 3 witnesses stated that they observed facility staff brush R1’s teeth once or twice in

Continued on LIC9099C

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

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 21-AS-20250908113646
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: 01/29/2026
NARRATIVE
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Continued from LIC9099C

the evenings. 1 of 3 witness interviews stated they did not observe R1’s teeth being brushed while they were there as R1 was already awake and ready for the day during visits.

Based on conflicting interview statements, record review, and observations made, this allegation is Unsubstantiated.

“Staff do not have proper training” – Complaint alleged that facility staff did not have proper training. Per complaint, facility staff did not know how to properly wipe R1 and did not put on new gloves after doing incontinence care to administer medication. Per complaint, R1 was prone to urinary tract infections and facility staff were not cleaning R1 from front to back. Complaint also stated that facility staff were not changing out their gloves causing R1 to get a bacterial infection in their eye.

Review of facility staff files showed that there was training conducted in September 2024 for infection control which reviewed items such as hand hygiene and using gloves as a protective barrier. Facility also conducted wound care training in June 2025 which reviewed symptoms and care needs during incontinence care. Interviews conducted with facility staff and witnesses revealed conflicting responses. 5 of 5 staff interviews stated that when providing incontinence care for R1, they change their gloves. 1 of 3 witness interviews stated that they observed facility staff to properly use and change out their gloves while providing incontinence care. 1 of 3 witness interviews stated that facility staff did not change their gloves after providing incontinence care and that facility staff did not wipe R1 properly. 1 of 3 witness interviews stated that they have observed facility staff to change their gloves but they could not recall if facility staff changed their gloves to administer medication after providing incontinence care. Interviews with Licensees stated that R1 aggressively picked and scratched at their eye and had to wear a glove and an eye patch to help prevent the scratching. Based on interviews and record review, Department is unable to determine if R1's bacterial infection occurred from improper glove usage or from another source.

Complaint also stated that facility staff did not have proper transfer training, stating that R1 received multiple bruises from being improperly transferred in their wheelchair or by the hoyer lift. Complaint provided photos to Department which showed bruises on R1's side and arm, and skin tears on R1's toes and arm. Interview with Licensees stated that R1 was on blood thinner medications and received physical therapy services multiple times a week where R1 would be lifted up under their arms and by their pants by family and by the physical therapists. Facility training documentation showed that hoyer lift and safe transfers training were done in June 2024. Facility also conducted transfer training in January 2025. Interviews conducted with facility staff and witnesses revealed conflicting responses. 5 of 5 staff interviews stated that R1 used a wheelchair and did not use a hoyer lift. 1 of 3 witness interviews stated that R1 was able to walk and did not use a hoyer lift. 1 of 3 witness interviews stated that R1 would get bruised or get skin tears because during transfers R1’s arm would hit the door frame or the wall. 1 of 3 witness interviews stated that they observed facility staff use a hoyer lift for R1.


Continued on LIC9099C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 21-AS-20250908113646
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: 01/29/2026
NARRATIVE
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Continued from LIC9099C

Per interview, they observed facility staff use the hoyer lift appropriately with 2 staff members. Based on interviews and record review, Department is unable to determine if R1's bruising resulted from staff transfers or from another source.

Based on conflicting interview statements, record review, and observations made, this allegation is Unsubstantiated.

“Facility did not ensure maintenance of resident’s personal care equipment”- Complaint alleged that R1’s airflow mattress was broken and caused R1’s pressure injury to worsen. Per complaint, R1’s airflow mattress was broken for over a month and the facility did not notice. Interview conducted with a witness revealed that R1’s airflow mattress was observed to have a deformity in the center. Per interview, R1’s mattress was ordered through a third party vendor for medical equipment and R1’s responsible party contacted the vendor for a new one. Interview further revealed that R1’s mattress was not replaced after a week and that the vendor stated that it was back-ordered. Per interview, the third party vendor did not notify R1’s responsible party or facility staff about the mattress.

Interview conducted with Licensees stated that the facility was not allowed to communicate with R1's Primary Care Physician or medical professional team and that all communication regarding medical care was done through R1’s responsible party.

Review of facility notes revealed that on 05/25/2025, R1's responsible party reported to facility management about R1's malfunctioning mattress and that that they would replace it. Review of mattress service receipts showed that on 06/06/2025, R1's mattress was delivered and installed.

Based on interviews conducted, record review, and observations made, this allegation is Unsubstantiated.

“Facility does not have enough staff for resident care needs” - Complaint alleged that the facility was observed to only have one staff member in the home on the following dates: 10/11/24, 10/26/24, 11/2/24, 11/9/24, 11/16/24, 11/23/24, 11/30/24, 12/7/24, 12/14/24, 12/16/24, 2/8/25, 2/28/25, 3/2/25, 4/14/25. Per complaint, R1 required two-person assistance. Review of R1’s care plan dated 08/25/2023 stated that R1 requires stand-by assistance for their Activities of Daily Living (ADLs) and had a one-on-one private caregiver.

Interview conducted with Licensees and Administrator stated that if a staff member is unable to work or calls in for their day shift, a night shift staff member will stay over to cover care. Interviews also revealed that the Administrator will take over direct care if a staff member is unavailable. 8 of 8 interviews with facility staff and witnesses stated that the facility had at least 2 staff members at the facility, with 1 of 8 interviews stating that they have seen at least 3 or 4 staff members at the home.

Continued on LIC9099C

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

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 21-AS-20250908113646
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: 01/29/2026
NARRATIVE
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Continued from LIC9099C

Review of facility’s personnel report and schedule for 2024 and 2025 showed that facility had at least 2 staff members scheduled. Review of facility time sheets for October, November, and December 2024 and for February, March and April 2025 showed that facility was staffed with two people in each home on the identified dates. Time sheets also showed that night shift staff members were clocked in on dates when a day shift staff member was not available.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated.

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: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 21-AS-20250908113646
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a)...each facility...shall provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review, Licensee did not comply with the
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Licensee to submit self-certification that an in-service training will be conducted with all direct staff reviewing The 6 Rights of Medications by POC due date of 01/30/2026. In-service Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. In-service training and
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section cited above. R1 received their Fosfomycin Tromethamine medication every 48 hours instead of every 72 hours as prescribed. This poses an immediate health and safety risk to residents in care.
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supporting documents to be submitted by POC due date of 02/09/2026.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8