Pueblo House

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Jan 12, 2026

The state marks this report as 12 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Neglect-Faciltiy staff are not meeting resident care needs

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 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.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20251008114439

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 19, 2025

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... 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...the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: 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'... 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.

Allegation investigated: Timely medical

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 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).the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20251008114439

Type of visit: Required - 1 Year

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 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 & 1st 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.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Shannan Hansen arrived announced to conduct a Post-Licensing Inspection and met with Administrator, David Cervantes-Vibat. There are 5 residents at facility with 2 having dementia diagnosis, none on hospice. Facility tour/inspection began at 9:25 AM: LPA toured the facility on 5/7/2024; 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. All bathrooms at the facility were supplied with paper towels and hand soap. 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 7/28/2023. 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 10:45 AM: A sample review of five residents & five staff records as well as two resident’s medications was conducted. LPA learned that 5 out of 5 residents have updated reappraisal/needs & care plan as well as medical assessments. Continue LIC 809-C 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 & 1st Aid certification. Medication Audit began at 1:20 PM: Medications were centrally stored in locked hallway closet although during tour LPA observed medications in unlocked kitchen drawer (see pic & LIC809-D). LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents. LPA 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. Facility has supplies enough to operate for more than 72 hours in an emergency. Disaster Drills are to be conducted quarterly and in different shifts (see LIC9102). 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. LPA Hansen is requesting Licensee to update and submit the following documents by 5/30/2024 to CCL: LIC 308 Designated LIC 500 Personnel Summary LIC 9020 Register of Facility Resident’s Proof of Liability Insurance Control of Property/Leasethe state’s words, verbatim · CDSS document, May 7, 2024

The state marks this report as 13 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Helena Rummonds and Licensing Program Manager (LPM) Victoria Bertozzi arrived at approximately 9:20AM for the purpose of continuing a Pre-Licensing inspection that was initiated on a visit dated 10/24/2023. LPA and LPM met with Applicant, David Cervantes-Vibat. Facility is a one story residence with six single bedrooms, three 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 122 degrees F which is not within regulation of 105 & 120 degrees F. Applicant agrees to slightly turn down the water heater to get the water temperature within regulation. 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. LPA and LPM discussed with Applicant a number of small repairs that will not interfere with licensing but should be repaired as soon as possible. The backyard was observed to have debris and toxins including paint cans and scrap wood. The bathrooms were observed to not have grab bars around the toilets. Applicant agrees to send photos of backyard area free from debris and toxins as well as grab bars for the toilets to LPA in order to move forward with licensing. Once noted areas are completed LPA will refer to application unit to continue with licensing.the state’s words, verbatim · CDSS document, Dec 15, 2023

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Oct 24, 2023

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): 3 COMP II Participants: David Cervantes-Vibat Interview Method: Telephone interview On October 03, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 3, 2023