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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804167
Report Date: 01/12/2026
Date Signed: 01/12/2026 04:53:10 PM

Document Has Been Signed on 01/12/2026 04:53 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 HOUSEFACILITY NUMBER:
286804167
ADMINISTRATOR/
DIRECTOR:		CERVANTES-VIBAT,DAVIDFACILITY TYPE:
740
ADDRESS:2600 BROWN STTELEPHONE:
(707) 254-4917
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 6DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Claribel Kemper, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Claribel Kemper, Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility is approved for six (6) non-ambulatory residents and has a Hospice waiver for two (2).

At approximately 11:15 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms tested within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Facility has at least two days of perishable food and DRP agrees to increase the facility's non-perishable food supply to meet the seven day requirement. Facility has an emergency water supply. Medications were centrally stored. However, LPA observed two residents' medications stored in the door of the facility refrigerator and accessible to residents in care, (see LIC809D). There is a covered seating area in the back yard with outdoor space for activities. Facility has internet available to residents in care and the phone was tested an operational. Facility agrees to purchase an internet access device and have it available to residents in care.

Facility's fire extinguishers were observed charged and were last serviced 07/2025. Facility Smoke and Carbon Monoxide detectors were tested and operational during today's inspection.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PUEBLO HOUSE
FACILITY NUMBER: 286804167
VISIT DATE: 01/12/2026
NARRATIVE
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Continued from LIC809...

Facility conducts bi-annual disaster drills with the most recent drill conducted 10/2025. LPA informed DRP that drills shall be conducted no less than quarterly per regulation. DRP conveyed understanding and agreed to comply moving forward. LPA observed facility's infection control plan and emergency disaster plan which was last updated 07/2023. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. Facility has a portable generator. DRP provided LPA with a copy of the facility's current liability insurance.

At approximately 1:00 PM, LPA reviewed three (3) staff files and three (3) resident files. Three (3) of three (3) staff files reviewed were missing proof of the required initial training hours and some of the annual training hours, and one (1) of three (3) staff files was missing a pre-employment health physical, (see LIC809D). All of the reviewed staff files had the remaining required paperwork. Three (3) of three (3) resident files reviewed were missing a consent for emergency medical treatment and one (1) was missing an appraisal needs and services plan, (see LIC809D). All resident files reviewed were observed to have all the remaining required paperwork. DRP and residents' families coordinate medical and dental visits for the residents and transportation to and from their appointments. Facility contracts with a third party vendor to provide transportation services as needed..

At approximately 4:30 PM, LPA reviewed medication records which are maintained in compliance with regulation. Facility does not manage P&I for residents.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment.

Exit interview conducted with DRP whose signature on form confirms receipt of documents. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2026 04:53 PM - It Cannot Be Edited


Created By: Julie Florio On 01/12/2026 at 04:09 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: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 one instance of medications found present accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2026
Plan of Correction
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Licensee to submit self-certification confirming review and understanding of regulation and agrees to comply with proper medication storage moving forward to CCL by POC due date 01/13/2026.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2026 04:53 PM - It Cannot Be Edited


Created By: Julie Florio On 01/12/2026 at 04:09 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: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff training records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee to submit self-certification confirming an understanding of the required initial, annual, and medication training and has ensured that all staff are in compliance with regulations to CCLD by POC due date 02/13/2026.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 resident records reviewed and found missing 1 or more of the required documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee to self certify that all residents have the required consent for emergency medical treatment form signed and a current appraisal needs and services plan to CCLD by POC dues date of 02/13/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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