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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804167
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:17:31 PM

Document Has Been Signed on 05/07/2024 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PUEBLO HOUSEFACILITY NUMBER:
286804167
ADMINISTRATOR/
DIRECTOR:		CERVANTES-VIBAT,DAVIDFACILITY TYPE:
740
ADDRESS:2600 BROWN STTELEPHONE:
(707) 254-4917
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
05/07/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:David Cervantes-Vibat, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived announced to conduct a Post-Licensing Inspection and met with Administrator, David Cervantes-Vibat. There are 5 residents at facility with 2 having dementia diagnosis, none on hospice.

Facility tour/inspection began at 9:25 AM:
LPA toured the facility on 5/7/2024; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has special care plan of operation and programming for residents with dementia.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. Cleaning supplies and toxins are locked in closet in the hallway and garage. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms at the facility were supplied with paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom showers. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees in bathroom faucets accessible to residents in care. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Fire Extinguisher was found to be last charged on 7/28/2023. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Facility has areas inside and outside for visiting and activities.

File Review began at 10:45 AM:


A sample review of five residents & five staff records as well as two resident’s medications was conducted. LPA learned that 5 out of 5 residents have updated reappraisal/needs & care plan as well as medical assessments. Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PUEBLO HOUSE
FACILITY NUMBER: 286804167
VISIT DATE: 05/07/2024
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A review of five staff records show, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1st Aid certification.

Medication Audit began at 1:20 PM:
Medications were centrally stored in locked hallway closet although during tour LPA observed medications in unlocked kitchen drawer (see pic & LIC809-D). LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Facility has supplies enough to operate for more than 72 hours in an emergency. Disaster Drills are to be conducted quarterly and in different shifts (see LIC9102). In addition, David Cervantes-Vibat, Administrator Certificate # 6067669740 expires 10/11/2025.


Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


LPA Hansen is requesting Licensee to update and submit the following documents by 5/30/2024 to CCL:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 9020 Register of Facility Resident’s

Proof of Liability Insurance

Control of Property/Lease

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 02:17 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/07/2024 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PUEBLO HOUSE
FACILITY NUMBER: 286804167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in medications were in unlocked kitchen drawer, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Admin to administer staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit document of name of training, date, with staff names, signatures & dates to CCL due date of May 17, 2024 to clear this citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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