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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602991
Report Date: 01/26/2024
Date Signed: 01/26/2024 04:02:03 PM


Document Has Been Signed on 01/26/2024 04:02 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:VERDUGO BOARDING HOMEFACILITY NUMBER:
374602991
ADMINISTRATOR:JACOME, RIGOBERTO GARCIAFACILITY TYPE:
740
ADDRESS:690 HELEN DRIVETELEPHONE:
(760) 757-8403
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 4DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Rigoberto GarciaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Rigoberto Garcia.

The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 4 residents, 1 of which was non-ambulatory. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Rigoberto Garcia and their certificate expired on 6/21/2023. Review of the Department's Pending Administrator list revealed Garcia's renewal application was received on 5/9/2023 and was determined to be incomplete.

During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to Rigoberto Garcia, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.2 degrees Fahrenheit and 118.6 degrees Fahrenheit in two common resident bathrooms. The facility’s internal temperature was measured at 71 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit.
Continued on LIC809-C page...
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VERDUGO BOARDING HOME
FACILITY NUMBER: 374602991
VISIT DATE: 01/26/2024
NARRATIVE
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LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.

LPA reviewed multiple resident and staff records. Review of resident records revealed that 1 of 4 resident records did not have an updated physician's report as required for a diagnosis of dementia. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiencies for updated physician's report, Department review of records, and Certified Administrator are cited per California Code of Regulation, Title 22 and noted on the attached LIC809-D pages.

An exit interview was conducted with Licensee Rigoberto Garcia, who refused to sign portions of the licensing documents. LPA left a hard copy of this report and the Licensee Appeal Rights (LIC9058 01/16) with Licensee Rigoberto Garcia.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: VERDUGO BOARDING HOME
FACILITY NUMBER: 374602991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 (a) All facilities shall have a qualified and currently certified administrator...

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 as the administrator certificate for the facility's designated Administrator expired on 6/21/2023, which poses a potential health and safety risk to 4 of 4 persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will reach out the Administrator Certificate Section to determine the missing information from their renewal application and will submit copies of requested information to complete the renewal application to the Department by the POC due date of 2/23/2024.
Type B
Section Cited
CCR
87705(c)(5)
87705(c) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

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 1 of 4 residents. R1's physician's report was last updated in 2021 and R1 has a diagnosis of dementia, which poses a potential health risk to 1 of 4 persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will speak to R1's family to arrange a doctor's appointment to get an updated LIC602 for R1. Licensee will submit a copy of R1's LIC602 to the Department by POC due date of 2/23/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/26/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: VERDUGO BOARDING HOME
FACILITY NUMBER: 374602991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(d)
87506 (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in allowing LPA to review residents records when requested. Licensee stated that LPA and the Department are not allowed to review resident records without resident or responsible party consent, which poses a potential personal rights risk to 4 of 4 persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee stated he will review regulation 87506 Resident Records and will submit a written document stating the Licensee has reviewed and understand regulation 87506 to the Department by POC due date of 2/9/2024.
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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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