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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002427
Report Date: 08/03/2022
Date Signed: 08/03/2022 01:11:37 PM


Document Has Been Signed on 08/03/2022 01:11 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VERONA COURT IIIFACILITY NUMBER:
306002427
ADMINISTRATOR:ARDA KARDJIAN/TAREK ELNABLFACILITY TYPE:
740
ADDRESS:25701 SABINA AVENUETELEPHONE:
(949) 215-3017
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Arda Kardjian, Julie GorordoTIME COMPLETED:
01:22 PM
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On 08/03/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Verona Court III. The purpose of today's visit was to conduct a Required 1 Year visit focusing primarily on Infection Control. At 11:26am, LPA Cho was allowed entry in the facility and met with Caregiver Margot Rivera after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Marito Rivera was also present at the facility. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for all visitors on a sign in sheet as well as residents. The facility screens but has stopped documenting temperatures for staff since March 2022. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The facility is licensed for six non-ambulatory residents of which six may be bedridden. The facility also has a Hospice waiver for six residents. There are currently six residents living in the facility of which three are receiving hospice services.

At 11:32am, LPA Cho conducted a tour of the physical plant along with Caregiver Marito Rivera. Administrator (Admin) Julie Gorordo entered the facility around 11:35am and assisted with the tour. The single story home consists of six resident bedrooms with two resident bathrooms. There are two staff bedrooms and one staff bathroom. The facility also has a living room, dining area, kitchen, laundry room, and an attached two car garage. LPA Cho observed the Complaint Poster in the incorrect size requirement of 8.5" x 11." Facility to obtain the Complaint Poster in the required size of 20" x 26." The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 109.4 degrees Fahrenheit in the Bathroom #1 and 109.7 degrees Fahrenheit in Bathroom #2.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERONA COURT III
FACILITY NUMBER: 306002427
VISIT DATE: 08/03/2022
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LPA Cho inspected the kitchen along with Admin Gorordo and Caregivers Marito and Margot. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho along with Admin toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit had all the required components except the first aid manual, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. An iPhone and smart phone is available for residents upon request.



At 12:24pm, Licensee Arda Kardjian entered the facility. Both Licensee and Administrator were present for the exit interview. Both were reminded of the importance of staying abreast with CCLD’s COVID-19 guidance and additional information by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: ccld.ca.gov.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. Exit interviews were conducted with Licensee Arda Kardjian and Administrator Julie Gorordo, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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