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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804167
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:05:29 AM

Document Has Been Signed on 12/15/2023 11:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PUEBLO HOUSEFACILITY NUMBER:
286804167
ADMINISTRATOR:CERVANTES-VIBAT,DAVIDFACILITY TYPE:
740
ADDRESS:2600 BROWN STTELEPHONE:
(707) 254-4917
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 6DATE:
12/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Applicant, David Cervantes-VibatTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Helena Rummonds and Licensing Program Manager (LPM) Victoria Bertozzi arrived at approximately 9:20AM for the purpose of continuing a Pre-Licensing inspection that was initiated on a visit dated 10/24/2023. LPA and LPM met with Applicant, David Cervantes-Vibat.

Facility is a one story residence with six single bedrooms, three bathrooms, and common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 122 degrees F which is not within regulation of 105 & 120 degrees F. Applicant agrees to slightly turn down the water heater to get the water temperature within regulation. Facility has sufficient items used for cooking and eating. Facility has a locked closet in the hallway used for centrally stored medications. Cleaning supplies and toxins are also locked in a closet in the hallway. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities.

LPA and LPM discussed with Applicant a number of small repairs that will not interfere with licensing but should be repaired as soon as possible. The backyard was observed to have debris and toxins including paint cans and scrap wood. The bathrooms were observed to not have grab bars around the toilets. Applicant agrees to send photos of backyard area free from debris and toxins as well as grab bars for the toilets to LPA in order to move forward with licensing.

Once noted areas are completed LPA will refer to application unit to continue with licensing.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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