374603413-12-9-2025-08-AS-JROO-DQSQ2U-20260129104744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603413
Report Date: 12/09/2025
Date Signed: 12/09/2025 03:24:51 PM

Unsubstantiated

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
10/03/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 08-AS-20231003160105

FACILITY NAME:	CASA VERDUGO		FACILITY NUMBER:	374603413
ADMINISTRATOR:	OZORIO-VERDUGO, NATALIA		FACILITY TYPE:	740
ADDRESS:	5164 E PARKER ST		TELEPHONE:	(760) 754-2504
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS:	DATE:	12/09/2025
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Natalia Verdugo		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable deaths
Staff restrained residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/09/2025 at 3:30PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger meet virtually via Teams to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Natalia Verdugo

During the course of the investigation, The Department conducted interviews with staff, residents, and witnesses. The Department collected and reviewed the following documents: R1’s facility file, R2’s facility file, R3’s facility file, R4’s facility file, R5’s facility file, R6’s facility file, and the facility staff roster.

On the allegation: Questionable deaths
R1 had atherosclerosis of coronary artery bypass, and carcinoma in situ of prostate. R1 was discharged from the skilled nursing facility (SNF) on 9/20/2023 and admitted to the facility on the same date. While at the SNF R1 was evaluated for hospice on 9/12/2023. R2 had unspecified encephalopathy, Chronic
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

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 2

Control Number 08-AS-20231003160105

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: 12/09/2025

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
26
27
28
29
30
31
32

...Continued from 9099
obstructive pulmonary disease (COPD) with acute exacerbation.R2 was discharged from SNF on 9/21/23. In R2’s discharge notes it states that “resident will be admitted to Cabrillo hospice services as resident requested”. R2 died three days later on 9/24/2023. R3 moved into the facility on 9/02/2023 after being discharged from Carmel Mountain Rehabilitation & healthcare. R3 was transferred to the facility by Cabrillo Hospice and their SNF discharge plan states that Cabrillo Hospice would be providing home health and DME for R3. R4 had compression fracture of t-11 and t-12. R4’s Transfer had been arranged by Cabrillo hospice, after they were discharged from Bella Vista Health Center on 8/28/2023. In R4’s Care notes from Bella Vista on 8/24/2023 state that R4 “may have hospice eval by Cabrillo Hospice and may discharge on 8/28”. R5 was on hospice and had been declining before their death on 9/22/23.

On the allegation: Staff restrained residents

R6 was admitted to the facility on 7/21/23 and was in hospice. R6 was admitted with DME and supplies including a hospital bed. At admission R6 was listed as a fall risk. In R6’s hospice notes there is no mention of encouraging R6 to get out of bed. The hospice care notes mention repositioning R6 on 8/21/23 and 9/4/23 and referred to teaching caregiver to turn R6 every two hours as tolerated by the patient.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2