<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002427
Report Date: 08/19/2021
Date Signed: 08/19/2021 11:57:36 AM

Document Has Been Signed on 08/19/2021 11:57 AM - 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: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Arda KardjianTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility was greeted and granted entry by caregiver. LPA met with Arda Kardjian, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator toured the facility. There are five residents in care and no active covid-19 cases. LPA observed two residents in living room and remainder in their rooms. All residents appeared clean and well taken care of. LPA observed required department posting, covid-19 postings in the facility and hand washing signs in the restrooms. All restrooms observed had soap/sanitized and appeared clean. Residents bedrooms appeared clean and sanitary with all required components. Facility is taking covid-19 precautionary measures daily. LPA observed a check in station with logs in the front door per covid guidelines. LPA observed the emergency disaster and evacuation plan posted at the facility. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC808 Mitigation plan and LPA Martinez approved the plan on site.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1