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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603413
Report Date: 07/21/2025
Date Signed: 07/21/2025 11:43:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20250328093905
FACILITY NAME:CASA VERDUGOFACILITY NUMBER:
374603413
ADMINISTRATOR:OZORIO-VERDUGO, NATALIAFACILITY TYPE:
740
ADDRESS:5164 E PARKER STTELEPHONE:
(760) 754-2504
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
07/21/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver Rosales Adrianna RamirezTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Lack of supervision resulting in resident elopement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to and was granted entry by Caregiver Rosales Adrianna Ramirez. LPA explained the purpose of the visit to Licensee Natalia Verdugo, who arrived shortly after LPA was granted entry.

During today's visit, LPA observed residents in care and interviewed the Licensee.

The Department’s investigation consisted of interviews with residents, staff and outside sources, review of facility records, and a tour of the facility. It was alleged that lack of supervision resulted in Resident 1’s (R1) elopement from the facility. Interviews with staff and outside sources and review of the incident report submitted to the Department by the facility on 4/3/2025 revealed that R1 did not return to the facility following their medical appointment on 3/26/2025.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
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 08-AS-20250328093905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA VERDUGO
FACILITY NUMBER: 374603413
VISIT DATE: 07/21/2025
NARRATIVE
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Interviews with staff and outside sources revealed that R1 had a diagnosis of major neurocognitive impairment and had limited verbal skills, however, medical and assessment records for R1 were not available during the investigation. Interviews with staff and outside sources revealed that R1 received outside transportation to and from appointments and R1 was not accompanied. The Licensee stated that R1’s responsible party had made an agreement with the transportation service to have the driver walk R1 to the facility’s front door, however the Department was unable to confirm this information. Interviews with the Licensee and outside sources revealed that on 3/26/2025, R1 had a medical appointment in the morning. Interviews with the Licensee and review of the incident report received on 4/3/2025 revealed that R1 was picked up from the facility by the transportation service at around 8:30am. Interviews with the Licensee revealed that R1 was supposed to return to the facility sometime around 2:00pm, however R1 did not return to the facility at that time. Information obtained during interviews was unclear if facility staff were notified by R1’s responsible party when R1 was on their way back to the facility via the transportation service. Sometime around 3:00pm, the Licensee called R1’s responsible party stating that R1 had not returned to the facility. Interviews with the Licensee revealed that R1’s responsible party called law enforcement to report R1 missing and both the Licensee and R1’s responsible party called the transportation service. According to Licensee and outside sources, the transportation service stated that R1 had been walked to the front door and entered the facility sometime between 2:30pm and 3:00pm. However, the Licensee stated staff claimed that R1 did not enter the facility following the appointment. The Licensee stated that the driver dropped R1 off at the front gate and R1 walked away from the property without supervision. While the details of how R1 was dropped off after R1's appointment are unclear, both the Licensee and outside sources confirmed that R1 walked away from the facility property without supervision. Interviews with the Licensee and outside sources confirmed that R1 was discovered to be at an address in the neighborhood by an outside individual, who contacted local law enforcement and paramedics at approximately 3:40pm. R1 was returned to the facility by law enforcement at approximately 5:30pm.
The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency was cited for lack of supervision and noted on the attached LIC9099-D page. Additionally, a civil penalty in the amount of $500 for lack of supervision was assessed and noted on an LIC421IM form.

An exit interview was conducted with Licensee Natalia Verdugo, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250328093905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA VERDUGO
FACILITY NUMBER: 374603413
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2025
Section Cited
CCR
87468.2(a)
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87468.2 (a) ...residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement has not been met as evidenced by:
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Licensee stated staff will obtain transportation contact information and will make sure that residents are brought to the front door of the facility following transportation. The Licensee will submit a copy of the staff sign in sheet to the Department by POC due date of 8/4/2025.
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Based on interviews and records review, the licensee did not comply with the section above in that R1 eloped from the facility without staff knowledge after being dropped off by a transportation service. This posed an immediate safety risk to 1 of 5 residents.
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Licensee stated that staff now take pictures and videos of residents when they use transportation services.
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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: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
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