374603413-1-27-2025-08-AS-RABA-DDBTXP-20250127140729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603413
Report Date: 01/27/2025
Date Signed: 01/27/2025 02:07:42 PM

Document Has Been Signed on 01/27/2025 02:07 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 VERDUGO		FACILITY NUMBER:	374603413
ADMINISTRATOR/ DIRECTOR:	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: 6	DATE:	01/27/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Licensee Natalia Ozorio-Verdugo		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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	Licensing Program Analysts (LPAs) Rebecca Borunda and Carmen Lopez conducted an unannounced Case Management Annual Continuation visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Administrator Natalia Verdugo. The facility is licensed for a maximum capacity of 6 bedridden residents, with a hospice waiver for 6 residents. During today’s visit, the facility had a census of 5 residents. The Administrator for the facility is Natalia Verdugo and their certificate was valid and current. During visits on 12/17/2024 and 1/27/2025, LPAs 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. The facility has a fenced-in pool in the backyard that is locked and inaccessible to residents. LPAs did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 119.2 and 111.2 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 69 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Natalia Verdugo, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPAs observed that 5 of 5 resident medications are not stored in their original container and are instead stored in multi-day pill boxes. LPA observed a minimum of 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. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. LPAs reviewed multiple resident and staff records. Continued on LIC809-C page…

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA VERDUGO	FACILITY NUMBER: 374603413
	VISIT DATE: 01/27/2025

NARRATIVE

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During the visit, LPAs determined that Staff 1 (S1) was not associated to the facility and did not have an active fingerprint clearance. [Administrator was provided with an LIC811 Confidential Names List to identify S1] Interviews with S1 and Administrator revealed that S1 had been working at the facility for more than 5 calendar days. LPAs notified Administrator that S1 could not be present or working at the facility until S1 was associated to the facility. LPAs observed S1 leave the facility during the visit. 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 following deficiencies were cited for medication stored in non-original containers and for staff without criminal background clearance and noted on the attached LIC809-D pages. Additionally, a civil penalty in the amount of $500 was assessed for staff without a criminal background clearance and noted on the attached LIC421BG form. LPAs also provided Administrator with an LIC9102TV Technical Violation regarding reporting requirements.

An exit interview was conducted with Administrator Natalia Verdugo, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC9102TV, and the LIC421BG and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/27/2025 02:07 PM - It Cannot Be Edited

Created By: Rebecca A Borunda On 01/27/2025 at 12:06 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that S1 was working at the facility for at least 5 calendar days and did not have a criminal background clearance, which poses an immediate safety risk to 5 of 5 residents in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	LPAs observed S1 leave the facility during the visit. Administrator will submit the LIC501, LIC503, LIC508, and valid identification to the Department to process S1's criminal background clearance and will obtain documentation of S1's completed criminal background clearance before S1 is able to be present in or work at the facility. Administrator stated that she will review staff records to verify that staff have valid fingerprint clearance and association.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Borunda

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/27/2025 02:07 PM - It Cannot Be Edited

Created By: Rebecca A Borunda On 01/27/2025 at 12:58 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that 5 of 5 residents had medications stored in multi-day pill boxes which poses a potential health risk to 5 of 5 residents in care.
	POC Due Date: 02/26/2025
	Plan of Correction
1 2 3 4	Administrator will look into options with residents' pharmacies to package medications together into bubble packs. Administrator will ask hospice agencies to provide medication training to Administrator and staff and provide the Department with a sign in sheet for the medication training by POC due date of 2/26/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Borunda

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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