Casa Verdugo

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Arian Golbakhsh and Eryn Kane conducted an unannounced Case Management visit to the facility. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to Staff Alexis Verdugo. Staff Carolina Garcia and Administrator Natalia Verdugo arrived later during the visit. During today's visit, there were four (4) residents in care. The purpose of LPAs' visit was to follow-up on a recent 3-day eviction request submitted by the facility for a resident identified as R1 (Please see LIC 811 for List of Confidential Names), which was denied by the Department on 8/26/26. LPAs provided guidance and consultation on eviction procedures with staff members Verdugo, Garcia, and Administrator Verdugo. During today's visit, an interview with R1 could not be conducted as they were out of the facility for medical treatment. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Verdugo to whom a copy of this report, the LIC 811, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 9, 2026

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Administrator Natalia Verdugo. During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff. LPA was away from the facility for approximately one hour between 12:40pm and 1:40pm. The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee issued an unlawful eviction to Resident 1 (R1). Continued on LIC9099-C page... Substantiated Review of R1's records revealed that on 4/16/2026, the Administrator provided R1 with a handwritten 30-day eviction notice stating that R1 required a higher level of care. Review of R1's pre-admission assessment documents revealed that R1 required assistance with transferring and repositioning, toileting, bathing, grooming, and dressing, and had expressions of frustration. Interviews with the Administrator confirmed that R1's care needs had not changed since R1's admission to the facility on 4/11/2026. Review of the 30-day eviction notice revealed that the document did not have all of the required elements, including the effective date of the eviction, resources for relocation, specific reasons for the eviction, or language required by Health and Safety Code 1569.683. Additionally, interviews with the Administrator confirmed that a copy of the eviction notice was not submitted to the Department within 5 calendar days of issuing the eviction notice. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, the allegation is deemed substantiated. The following deficiency was cited for unlawful eviction and noted on the attached LIC9099-D page. 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 03/22).the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 08-AS-20260423163421

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1) · Plan of correction due date: May 29, 2026

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction... (1) The notice to quit shall include the following information: This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not comply with the section cited above in that the eviction notice issued to R1 did not contain all required elements, which poses a potential personal rights risk to 4 of 4 residents in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Administrator will attend training regarding eviction procedures and will submit proof of training to the Department by POC due date of 5/29/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda 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 Verdugo. The facility has a licensed capacity of 6 bedridden residents and has a hospice waiver for 6 residents. During today’s visit, the facility had a census of 4 residents, 2 of which were on hospice. The Administrator for the facility is Natalia Verudgo and their certificate was valid and current. During today’s visit, LPA inspected each room of the facility, including resident and staff rooms, common bathrooms, kitchen, garage, common areas, and outside space. The facility has a fenced-in pool in the backyard that is locked and inaccessible to residents. No delayed egress or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient temperature and water temperature were measured within regulatory requirements. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Natalia Verdugo, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records. An LIC9102TA Technical Advisory regarding annual visits with medical professionals was provided. No deficiencies were cited on today's date. An exit interview was conducted with Administrator Natalia Verudgo, whose signature below confirms receipt of a copy of this report, the LIC9102TA, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jan 21, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Questionable deaths Staff restrained residents

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 ...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.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 08-AS-20231003160105

Allegation investigated: Lack of supervision resulting in resident elopement

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to and was granted entry by Caregiver Rosales Adrianna Ramirez. LPA explained the purpose of the visit to Licensee Natalia Verdugo, who arrived shortly after LPA was granted entry. During today's visit, LPA observed residents in care and interviewed the Licensee. The Department’s investigation consisted of interviews with residents, staff and outside sources, review of facility records, and a tour of the facility. It was alleged that lack of supervision resulted in Resident 1’s (R1) elopement from the facility. Interviews with staff and outside sources and review of the incident report submitted to the Department by the facility on 4/3/2025 revealed that R1 did not return to the facility following their medical appointment on 3/26/2025. Continued on LIC9099-C page... Substantiated Interviews with staff and outside sources revealed that R1 had a diagnosis of major neurocognitive impairment and had limited verbal skills, however, medical and assessment records for R1 were not available during the investigation. Interviews with staff and outside sources revealed that R1 received outside transportation to and from appointments and R1 was not accompanied. The Licensee stated that R1’s responsible party had made an agreement with the transportation service to have the driver walk R1 to the facility’s front door, however the Department was unable to confirm this information. Interviews with the Licensee and outside sources revealed that on 3/26/2025, R1 had a medical appointment in the morning. Interviews with the Licensee and review of the incident report received on 4/3/2025 revealed that R1 was picked up from the facility by the transportation service at around 8:30am. Interviews with the Licensee revealed that R1 was supposed to return to the facility sometime around 2:00pm, however R1 did not return to the facility at that time. Information obtained during interviews was unclear if facility staff were notified by R1’s responsible party when R1 was on their way back to the facility via the transportation service. Sometime around 3:00pm, the Licensee called R1’s responsible party stating that R1 had not returned to the facility. Interviews with the Licensee revealed that R1’s responsible party called law enforcement to report R1 missing and both the Licensee and R1’s responsible party called the transportation service. According to Licensee and outside sources, the transportation service stated that R1 had been walked to the front door and entered the facility sometime between 2:30pm and 3:00pm. However, the Licensee stated staff claimed that R1 did not enter the facility following the appointment. The Licensee stated that the driver dropped R1 off at the front gate and R1 walked away from the property without supervision. While the details of how R1 was dropped off after R1's appointment are unclear, both the Licensee and outside sources confirmed that R1 walked away from the facility property without supervision. Interviews with the Licensee and outside sources confirmed that R1 was discovered to be at an address in the neighborhood by an outside individual, who contacted local law enforcement and paramedics at approximately 3:40pm. R1 was returned to the facility by law enforcement at approximately 5:30pm. The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency was cited for lack of supervision and noted on the attached LIC9099-D page. Additionally, a civil penalty in the amount of $500 for lack of supervision was assessed and noted on an LIC421IM form. An exit interview was conducted with Licensee Natalia Verdugo, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 08-AS-20250328093905

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a) · Plan of correction due date: Aug 4, 2025

87468.2 (a) ...residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above in that R1 eloped from the facility without staff knowledge after being dropped off by a transportation service. This posed an immediate safety risk to 1 of 5 residents.the state’s words, verbatim · CDSS document, Jul 21, 2025

Plan of correction: Licensee stated staff will obtain transportation contact information and will make sure that residents are brought to the front door of the facility following transportation. The Licensee will submit a copy of the staff sign in sheet to the Department by POC due date of 8/4/2025. Licensee stated that staff now take pictures and videos of residents when they use transportation services.

Type of visit: POC

Licensing Program Analyst (LPA) Hannah Rodgers conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Licensee Natalia Verdugo. The purpose of the visit was to verify if the deficiency issued on 4/02/2025 had been corrected. On 4/02/2025, the licensee was issued a deficiency with a correction due date of 5/02/2025. During today’s visit, LPA Rodgers verified that the licensee corrected the deficiency regarding Resident 1 and Resident 2's (R1 and R2) incomplete records. Review of resident records verified that R1 and R2 now had complete and current records located in their files. Therefore, the deficiency for resident records is corrected. LPA provided Licensee Verdugo with a letter of Deficiency Cleared. An exit interview was conducted with Licensee Verdugo, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Case Management - Deficiencies

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).the state’s words, verbatim · CDSS document, Apr 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 2, 2025

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: 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.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: 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.

Type of visit: Case Management - Annual Continuation

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… 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).the state’s words, verbatim · CDSS document, Jan 27, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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).the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Rebecca Ruiz conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Caregiver Araceli Ramirez. Licensee Natalia Verdugo arrived during the visit. The purpose of the visit was to verify if the two deficiencies regarding resident and staff files issued on 1/19/2024 had been corrected by the correction due date of 2/16/2024. During today’s visit, LPA Ruiz spoke with Licensee Natalia and Caregiver Carolina Garcia regarding the POC documentation and reviewed resident and staff records. Resident and staff records were not complete and the Licensee confirmed that the records present at the facility had not been updated. An immediate civil penalty of $100 per day totalling $400 for 2/17/2024 to 2/20/2024 is being assessed on an LIC421FC for failure to correct the resident records by POC due date. The Licensee completed the required paperwork for resident records during the visit, which LPA verified. Therefore, the deficiency 87506(a) regarding resident files has been corrected as of 2/20/2024 and LPA provided Licensee with a letter of Deficiency Cleared. Staff records were not complete and the Licensee stated that the delay was due to waiting on availability for doctor appointments. Licensee requested a POC due date extension, which LPA granted until 3/19/2024. LPA provided Licensee with technical assistance regarding requesting POC due date extensions. An exit interview was conducted with Licensee Natalia Verdugo, whose signature below confirms receipt of a copy of this report, the LIC421FC, LIC178, LIC9102TA, LIC811, Letter of Deficiency Cleared, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Feb 20, 2024

Type of visit: Required - 1 Year

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 Caregiver Araceli Ramirez. Administrator Natalia Verdugo arrived during the visit. The facility is licensed for a maximum capacity of 6 bedridden residents. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 4 residents, none of which were bedridden and 1 of which was on hospice. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Natalia Verdugo and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff 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. According to Natalia Verdugo, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 119.5 degrees Fahrenheit and 119.8 degrees Fahrenheit in two common resident bathrooms. The facility’s internal temperature was measured at 71 degrees Fahrenheit. LPA observed unlocked hazardous and toxic chemicals in the facility kitchen, facility garage, and under the sink in a common bathroom for resident use. Administrator removed the hazardous and toxic items and locked them in the garage during the visit. LPA observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed 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 37 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. Continued on LIC809-C page... LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Review of resident records revealed that 4 resident records were incomplete and were missing documents. Review of 5 staff files revealed that 3 staff records were incomplete and were missing documents. 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 Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiencies for unlocked hazardous and toxic chemicals, incomplete staff records, and incomplete resident records were cited per California Code of Regulations Title 22 and noted on the attached LIC809-D pages. An exit interview was conducted with Administrator Natalia Verdugo, whose signature below confirms receipt of a copy of this report, LIC811 Confidential Names List, LIC9102TV, and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Jan 19, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

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).the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 31, 2023

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: 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.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: 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.