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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004113
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:24:12 PM


Document Has Been Signed on 09/15/2022 03:24 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 IXFACILITY NUMBER:
306004113
ADMINISTRATOR:ARDA KARDJIANFACILITY TYPE:
740
ADDRESS:29842 ANDREA WAYTELEPHONE:
(949) 545-6698
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Arda KardjianTIME COMPLETED:
03:45 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 explained the reason for the visit. LPA met with Administrator Arda Kardjian. Facility is a single story home with 8 bedrooms (3 are for staff), living room, dining room, kitchen, 2 bathrooms, and a 2 car garage that is used for storage. LPA and staff toured the facility. Hot water temperature measured 105.0 degrees Fahrenheit in both bathrooms. All bathrooms were clean and operational. LPA observed all of the resident rooms had the required furnishings. Smoke detectors/carbon monoxide detectors tested operational. LPA inspected the kitchen. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand. The kitchen is clean and organized. LPA observed the medication is kept locked in a kitchen cabinet. LPA toured the backyard. No bodies of water observed. There is a shaded seating area in the backyard for residents to sit outside. The backyard exit gate is operational. 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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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