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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603413
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:11:57 PM

Document Has Been Signed on 10/04/2023 02:11 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
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: 4DATE:
10/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Natalia VerdugoTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to cite a deficiency unrelated to a complaint investigation. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Natalia Verdugo.

During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records and spoke with the Administrator.

During today's visit, LPA reviewed 14 files for residents who were present at the facility for the 2023 calendar year but were no longer current residents (Residents 1-14). LPA spoke with Administrator Natalia who informed LPA that the majority of her previous residents had passed away at the facility. The Administrator informed LPA that she would call the Department when an unusual incident occurred at the facility but that she did not call the Department for a resident's death. The Administrator stated that she did not submit incident or death reports to the Department. Review of the incident and death reports submitted to the Department did not reveal any incident or death reports submitted to the Department from the facility for R1 - R14.

The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page.

LPA provided the Administrator with copies of LIC624 and LIC624A and regulation 87211 Reporting Requirements. An exit interview was conducted with Administrator Natalia Verdugo, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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 10/04/2023 02:11 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 10/04/2023 at 01:36 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: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement has not been met as evidenced by:
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Administrator stated she will take an online training regarding reporting requirements and submit proof of completion to the Department by POC due date of 10/31/2023.
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Based on interviews and records review, the Administrator did not submit death reports to the Department for the deaths of R1-R14. This poses a potential safety risk to 4 of 4 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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