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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603413
Report Date: 04/02/2025
Date Signed: 04/02/2025 02:31:56 PM

Document Has Been Signed on 04/02/2025 02:31 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: 5DATE:
04/02/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee Natalia VerdugoTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to cite a deficiency observed during a complaint visit that is unrelated to the complaint allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Licensee Natalia Verdugo.

During the unrelated complaint visit, LPA reviewed resident records and determined that the records for Resident 1 and Resident 2 (R1 and R2) were incomplete. [Licensee was provided with an LIC811 Confidential Names List to identify R1 and R2] Review of both resident's files and an interview with Licensee Verdugo revealed that both R1 and R2 moved into the facility in early March 2025, and as of 4/2/2025, both R1 and R2 did not have medical assessments or appraisal documents on file. During the visit, Licensee Verdugo was able to obtain and provide LPA with an electronic copy of R2's medical assessment dated 3/5/2025.

Therefore, a deficiency regarding resident records is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Licensee Natalia Verdugo, whose signature below confirms receipt of a copy of this report, LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
NAME OF LICENSING PROGRAM MANAGER: Jennifer Lott
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/02/2025 02:31 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 04/02/2025 at 11:15 AM
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: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
87506(a)

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87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...

This requirement is not met as evidenced by:
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Licensee will fill out and obtain copies of required documents for R1 and R2 and maintain those records at the facility. Licensee will notify LPA via email when the records are complete by POC due date of 5/2/2025.
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Based on interviews and record review, the licensee did not comply with the section cited above in that 2 of 5 resident records (R1 & R2) were incomplete which poses a potential health risk to 2 of 5 residents in care.
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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.
Jennifer Lott
NAME OF LICENSING PROGRAM MANAGER:
Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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