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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603413
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:49:38 PM

Document Has Been Signed on 12/17/2024 03:49 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CASA VERDUGOFACILITY NUMBER:
374603413
ADMINISTRATOR/
DIRECTOR:		OZORIO-VERDUGO, NATALIAFACILITY TYPE:
740
ADDRESS:5164 E PARKER STTELEPHONE:
(760) 754-2504
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Licensee Natalia Ozorio-VerdugoTIME VISIT/
INSPECTION COMPLETED:
03:50 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 Administrator Natalia Ozorio-Verdugo.

During today's visit, LPA toured the facility, reviewed facility records, and observed residents in care. Review of resident records revealed that the LIC602 physician's report for Resident 1 (R1) noted that R1 had a diagnosis of dementia and was dated 2/15/2023 and the LIC602 physician's report for Resident 2 (R2) noted that R2 had a diagnosis of dementia and was dated 6/6/2023. [Administrator was provided with an LIC811 Confidential Names List to identify R1 and R2]. LPA was away from the facility for approximately one hour between 1:15pm and 2:15pm. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

The following deficiency was cited for annual medical assessments and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Natalia Ozorio-Verdugo, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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Document Has Been Signed on 12/17/2024 03:49 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 12/17/2024 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CASA VERDUGO
FACILITY NUMBER: 374603413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (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 ensure that residents with a diagnosis of dementia, specifically R1 and R2, had a medical assessment that was conducted annually. This poses a potential health risk of 2 of 6 residents in care.
POC Due Date: 01/16/2025
Plan of Correction
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Administrator will contact R1 and R2's responsible parties to obtain medical appointments for both residents to be reassessed and obtain new LIC602s. Administrator will submit copies of the new LIC602s for R1 and R2 to the Department by POC due date of 1/16/2025.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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