286804167-2-25-2025-21-AS-ADEZ-DE8TAY-20250225133420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804167
Report Date: 02/25/2025
Date Signed: 02/25/2025 01:34:37 PM

Document Has Been Signed on 02/25/2025 01:34 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	PUEBLO HOUSE		FACILITY NUMBER:	286804167
ADMINISTRATOR/ DIRECTOR:	CERVANTES-VIBAT,DAVID		FACILITY TYPE:	740
ADDRESS:	2600 BROWN ST		TELEPHONE:	(707) 254-4917
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 6		CENSUS: 6	DATE:	02/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPAs) Deniz and Arnhold arrived announced to conduct an annual one year required Inspection and met with Caregiver/House manager, Mariateres Varias. There are 6 residents at facility with 2 having dementia diagnosis, two on hospice.

Facility tour/inspection began at 9:25 AM:
LPA toured the facility on 2/25/2025; 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. 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 July 2024. 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 10:35 AM:

A sample review of five residents & five staff records as well as two resident’s medications was conducted. During the staff file reviews 2 out of 5 staff didn't have health screening (Citation given. LIC809-D). LPAs learned that 5 out of 5 residents have updated reappraisal/needs & care plan as well as medical assessments.

Continue LIC 809-C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PUEBLO HOUSE	FACILITY NUMBER: 286804167
	VISIT DATE: 02/25/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 & 1^st Aid certification.

Medication Audit began at 12:30 PM:
Medications were centrally stored in locked hallway closet although during tour LPAs observed medications of 3 out of 6 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to have all medications entered for residents.

LPAs 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. Disaster Drills are to be conducted quarterly. 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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/25/2025 01:34 PM - It Cannot Be Edited

Created By: Ali Deniz On 02/25/2025 at 01:01 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff files. The two staff files did not have health secreening report which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	The Licensee agrees to provide self certification that all staff completed health secreening report by due plan of correction date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Ali Deniz

LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3