Three Home Village I

Type of visit: Case Management - Annual Continuation

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Facility Staff. Licensee/Administrators, Erik Flatt, Adam Waskow, and Administrator, Matthew Riformo arrived during visit at approximately 9:20AM. 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 6 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, 2 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 2025. Smoke detectors and carbon monoxide detectors were tested and operational. During walk through, LPA observed prepoured medications for afternoon and evening medication (technical violation issued, regulation 87465(h)(5)). 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. Continued on LIC809C Continued from LIC809 LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificates Documents to be submitted to Community Care Licensing (CCL) by due date of 11/16/2025. No Deficiencies Cited during Visit. Exit interview conducted. Copy of report and LIC9102 (Technical Advisories/Violations) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 16, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 9:35AM, 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 5 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 reviewed staff files. Staff files had current First Aid and CPR certification. 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 02/15/2027. Facility's last emergency/disaster drill was conducted September 2025. LPA discussed the following topics with Licensees and Administrator: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA unable to complete annual visit. Annual continuation to be conducted at a later date. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrators, Erik Flatt, 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 6 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, 2 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. During walkthrough, LPA observed ants on and in the facility freezer. LPA did not observe any ants in the food (technical assistance issued, LIC9102, 87555(b)(27)). 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 Continued from LIC809 LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) 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 and LIC9102 (Technical Advisories/Violations) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 15, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 11/21/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrators, Adam Waskow & Matthew Riformo. The facility is a one story building licensed for 6 non-ambulatory and 2 bedridden residents, along with a hospice waiver capacity of 3. The facility currently provides care for 6 residents, 1 of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrators, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 9/29/2023 at the time of visit. Smoke and carbon monoxide detectors found throughout the facility were interconnected, and found to be in working order. Additional carbon monoxide detectors were also tested and functioning. Auditory alarms at all exits for residents with dementia were tested and fully functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food replenished once per week. Food stored in the kitchen and separate food storage in the backyard were properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions listed in each resident's file. Toxins are stored in supply closets and under kitchen sinks throughout the facility all of which were found to be secured. There was a supply of PPE, hygiene, continence care and paper products available for residents. All resident’s rooms have lighting & appropriate furnishing and found to be in clean and safe condition. Water was measured at faucets accessible to residents and measured at 112.8 degrees F which is within regulation. Continued onto LIC809-C Medications were located in designated kitchen cabinets and found to be secured. LPA conducted a spot check of medications and found all administering and records including centrally stored medication records and medication administration records to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private bedrooms, visited by family members or in the outdoor patio spaces for leisure. Residents are visited by family frequently and interact with one another in the dinning area, common spaces as well as in resident private rooms. LPA conducted a sample file review for staff and found staff to have 1st Aid & CPR training certification up to date and on file. All staff have completed annual and initial on-boarding training requirements and are on file. All staff have also been properly associated to the facility and confirmed on the Guardian System roster. Upon a spot review of resident files, LPA found residents to have all current required documentation on file including Service Plans and Physician's Reports. LPA and Administrator discuss the appropriate dimensions for Complaint Poster PUB475 and to provide updated photo corrections to CCLD. Technical Advisory issued. Administrator, Adam Waskow's Administrator Certification 6017406740 is currently active through 1/16/2024. LPA requested the following documents be sent to CCL by COB 12/21/2023: LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Nov 21, 2023