Three Home Village 2

Allegation investigated: Staff did not administer medications as prescribed

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 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. 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 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 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 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.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 21-AS-20250908113646

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 30, 2026

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 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.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: 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 supporting documents to be submitted by POC due date of 02/09/2026.

Allegation investigated: Staff do not provide a safe environment for residents in care Staff accepted a resident that needs a higher level of care

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 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.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20250717142711

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 Certificate 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 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 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.the state’s words, verbatim · CDSS document, Nov 15, 2024

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, Erik Flatt & 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, none of which are 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. all found to be in clean and safe condition. Water was measured at faucets accessible to residents and measured between 106.0 and 109.0 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, Erik Flatt's Administrator Certification 6017406740 is currently active through 6/28/2024. LPA requested the following documents be sent to CCL by COB 12/21/2022: LIC 308 Designated Facility Responsibility 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