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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002554
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:03:12 PM


Document Has Been Signed on 11/29/2022 04:03 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 IVFACILITY NUMBER:
306002554
ADMINISTRATOR:ARDA KARDJIANFACILITY TYPE:
740
ADDRESS:23961 STILLWATER LANETELEPHONE:
(949) 249-9047
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Julie SandersTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Julie Sanders. LPA explained the reason for the visit. Facility has 7 bedrooms, 2 bathrooms, living room, dining room, kitchen and a 2 car garage. LPA and Administrator toured the facility. LPA observed both bathrooms are clean and operational. Hot water measured 108.0 degrees Fahrenheit in both bathrooms. LPA observed the kitchen is clean and organized. Knives are kept locked in a kitchen drawer. LPA observed medication is kept locked in the hallway closet. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed all resident rooms had the required furnishings. LPA inspected the first aid kit and it had all the required elements. LPA and Administrator toured the garage. The garage is kept locked and used for storage. LPA observed the See Something Say Something poster (PUB 475) in the entry way of the facility. The poster is 20 by 26 inches. Smoke detectors/carbon monoxide detectors tested operational. LPA and the Administrator toured the backyard. LPA observed a table, chairs and umbrella in the patio for residents to sit outside. The exit gate is operational. No bodies of water observed. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures and reporting requirements. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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