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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 03:27:18 PM

Substantiated


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:
01:30 PM
MET WITH:Cristina Mallari, Designated Responsible PartyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect-Faciltiy staff are not meeting resident care needs
INVESTIGATION FINDINGS:
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On 11/18/2025, at approximately 1:30 PM, 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 neglect-faciltiy staff are not meeting resident care needs 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 facility staff had observed a slow decline in R1's condition over the "past few months." S1 stated that R1 moved in to facility on 10/24/2023 and was non-ambulatory and eating independently at that time and R1's LIC602 dated 10/24/2023 confirms this.

Continued on LIC9099C...
Substantiated
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 3
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 R1 began refusing to get out of bed and transferring to the chair around mid-July 2025 and R1's legs have grown stiff in this time. Additionally, S1 stated that since August of this year R1 has started requiring 1:1 assistance with feeding at all meals due to R1's inability to direct utensils to their mouth on their own.

S1 was unable to provide proof of any communication with R1's responsible party regarding their change in condition prior to R1 being sent to the hospital on 10/2/2025. Additionally, S1 was unable to provide proof of any communication with or evaluation by a medical professional during the time frame between when the change of condition was first observed by facility staff and when R1 was taken to the ER on 10/02/2025. Subsequently, S1 took R1 to their PCP for an evaluation as evidenced by an after visit summary dated 10/09/2025. S1 stated that there was a discussion about Hospice for R1 but to date there is no documentation that R1 is on Hospice.

Based on observations made, interviews conducted and records obtained, the allegation of neglect-faciltiy staff are not meeting resident care needs for R1 is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided.
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2025
Section Cited
CCR
87466
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87466 Observation of the Resident
When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the...
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condition. This poses a Health, Safety and/or Personal Rights risk to residents in care.

Licensee shall self-certify that staff training has been scheduled regarding observation of changes in residents'...
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resident's responsible person. This requirement is not met as evidenced by:
Based on records reviewed and interviews conducted, Licensee did not ensure that R1 was seen by a medical professional and that the responsible party was notified of the change in...
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condition, notifying the residents' responsible party, seeking medical attention, and documentation to CCL by POC due date of 11/19/2025. Proof of training and a copy of R1's 10/09/2025 LIC602 shall be submitted to CCL by 12/19/2025.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3