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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006243
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:06:57 PM


Document Has Been Signed on 01/29/2024 04:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VERONA COURT XIVFACILITY NUMBER:
306006243
ADMINISTRATOR:KARDJIAN, ARDAFACILITY TYPE:
740
ADDRESS:23952 HILLHURST DR.TELEPHONE:
(949) 230-3797
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 4DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Arda KardjianTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Arda Kardjian and explained the reason for the visit. Facility is a 7 bedroom house (one bedroom is for staff) with a kitchen, living room with a fireplace, 6 bathrooms, dining room and a 2 car garage. LPA and Administrator toured the facility. LPA observed the PUB 475 see something, say something poster in the entrance way of the facility. LPA observed the fireplace in the living room is screened. Smoke detectors and carbon monoxide detectors tested operational. Hot water measured 111.7 degrees Fahrenheit in bathroom number 1. LPA observed the kitchen is clean and organized. The fire extinguisher in the kitchen is fully charged. There is a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand in the kitchen. LPA observed the knives and sharp objects are kept secured. All cleaning supplies are kept locked in a closet. LPA observed all the medications are kept locked in a kitchen cabinet. LPA observed all resident bedrooms had the required linen and furnishings. LPA and Administrator toured the garage. The garage is kept locked and is off limits to residents. The garage is used for storage and has a washer and dryer. LPA and Administrator toured the outside of the facility. The backyard has a covered patio with 2 seating areas for residents. Both backyard exit gates are operational and latched. No bodies of water observed. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 4 out of 4 resident files. No discrepancies observed. LPA reviewed 4 out of 4 resident medications and medication records, no discrepancies observed. LPA reviewed 2 out of 4 staff files. No discrepancies observed. LPA interviewed staff and residents. LPA inspected the first aid kit. The first aid kit had all the required elements. No deficiencies observed during the visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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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