<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804167
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:33:46 PM


Document Has Been Signed on 10/24/2023 03:33 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:CERVANTES-VIBAT,DAVIDFACILITY TYPE:
740
ADDRESS:2600 BROWN STTELEPHONE:
(707) 254-4917
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 4DATE:
10/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Applicant, David Cervantes-VibatTIME COMPLETED:
03:45 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 (LPA) Victoria Bertozzi arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, David Cervantes-Vibat. Applicant has applied for a Change of Ownership of an existing Residential Care for the Elderly Facility.

Facility is a one story residence with six single bedrooms, two bathrooms, and common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 115.6 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked closet in the hallway used for centrally stored medications. Cleaning supplies and toxins are also locked in a closet in the hallway. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities.

Facility is currently undergoing repairs and upgrades that Applicant anticipates will be completed within the next two weeks . LPA discussed with Applicant the importance of ensuring resident safety while making repairs including but not limited to keeping items that may pose a risk inaccessible to residents such as paint, tools and other materials and making construction areas off limits to residents.

Facility received an approved fire clearance dated July 21, 2023 that allows for six non-ambulatory residents.

LPA will return once all repairs are complete to finish Prelicensing inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 1