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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804167
Report Date: 11/18/2025
Date Signed: 11/18/2025 03:25:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20251008114439
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:
11/18/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cristina Mallari, Designated Responsible PartyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Timely medical
INVESTIGATION FINDINGS:
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On 11/18/2025, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to follow up on complaint investigation regarding LIC802 - Complaint Report #21-AS-20251008114439, which was received by Community Care Licensing (CCL) on 10/08/2025, and to deliver complaint investigation findings. LPA met with Cristina Mallari, Designated Responsible Party (DRP). Reporting Party (RP) alleges that facility did not seek timely medical attention for Resident 1 (R1).

LPA conducted 10-day complaint investigation visit on 10/13/2025 and obtained documents, made observations, and conducted interviews. During interview with Staff 1 (S1) it was revealed that on 10/02/2025 Staff 2 (S2) reported to S1 that R1 was agitated. S1 stated that S2 informed them that day that R1's urine output had been darker and more odorous for "a couple of days."

Continued on LIC9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20251008114439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2025
NARRATIVE
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 Continued from LIC9099...

S1 stated that they had facility staff immediately call the advice nurse who then instructed facility to send R1 to the ER for evaluation where R1 was later diagnosed with a urinary tract infection (UTI) and discharged home the same day with three days of antibiotics per hospital discharge summary dated 10/2/2025. As of 10/13/2025 facility visit, S1 stated that R1's UTI was resolved and that R1 was seen by their primary care physician (PCP) for a follow up visit on 10/9/2025. The after visit summary from this follow up appointment does not mention R1's UTI. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding this allegation.

Based on interviews conducted and records obtained, the allegation that facility did not seek timely medical attention for R1 is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2